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Section on PAIN

JANUARY

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SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

Femoral Shortening for
Equalization of Leg Length

i GEORGE M. HART, M.D.

Minot, North Dakota

EQUALIZATION OF DISCREPANCIES ill leg length
has long been considered an important prob-
lem in orthopedic practice. Compensation for
minor differences can readily be made by simply
applying a lift to the sole and heel of the shoe on
the short side. As the difference in length of the
limbs increases, however, the elevated shoe be-
comes not only more unsightly but more difficult
and unwieldy for the patient. It is natural, there-
fore, that reports of surgical measures to resolve
the problem appear earlv in the literature of
orthopedic surgery.

In general, two methods of approach have
been considered: (1) shortening of the long leg
and ( 2 ) lengthening of the short leg. Shortening
of the long leg may be accomplished bv one of
two methods— arrestment of longitudinal growth
by cancellation of epiphysial growth, as first ad-
vocated bv Phemister1 in 1933, or by actual short-
ening of one of the bones of the extremity by
segmental resection. It is with the latter method
that this article is concerned.

Steindler2 noted that femoral shortening was
first carried out in 1847 by Rizzoli, whose claim
of priority has not, however, found much recog-
nition. His method was osteotomy with overrid-
ing of the bone fragments. Two other authors

george m. hart is consultant in orthopedic surgery
at Veterans Hospital , Minot; on the staffs of Trinity
Ho.spital and the Northwest Clinic, both in Minot;
and surgeon for the Soo Line Railroad.

used similar technics, Mayer in 1850 and Sayre
in 1863. In 1908, Glaessner3 reported 2 cases and
Deutschlander4 described fixing the fragments
with an aluminum plate and screws. Shands5
recorded 3 cases in 1917, using wire sutures for
fixation of the bone ends. Fassett9 in 1918 des-
cribed fixation of the fragments with a Lane
plate in 3 cases. In another case, he used a
tongue and groove osteotomy. Royle,7 in 1923,
described 5 cases, 4 of which were fixed with in-
tramedullary pegs and 1 with a Lane plate.

In 1935, White8 described a method of femoral
shortening which has since been widely accept-
ed. He performed a transverse osteotomy of the
mid-third of the femur. The bone fragments
were allowed to override the correct amount and
were fixed by obliquely placed, removable pins.
A plaster hip spica cast was applied from the
toes to the ribs with the hip slightlv flexed and
abducted. The knee was similarly flexed, and the
pins were incorporated in the cast. Eonr weeks
postoperatively the pins were removed. The
cast was maintained for an additional month
and then removed if x-ray examination revealed
sufficient callus formation.

In 1940, Harmon,9 in discussing the surgical
treatment of unequal leg length, noted that
either the tibia or femur could be shortened as
much as 3 in. He felt that femoral shortening
was usually more applicable. The site elected
for this procedure was at the junction of the
middle and lower thirds of the femur. The author

used a Gigli saw to sever the bone transversely
and then removed the desired excess bone with
a hand saw. The excised bone was split into
several fragments, one of which was constructed
to fit snugly as an intramedullary graft. The re-
maining pieces of bone were placed across the
osteotomy site as onlay grafts. Bronze aluminum
wire was used in a number of cases to prevent
separation of the bone ends. The author con-
cluded that although epiphysial arrest was the
most conservative surgical method of equalizing
leg length, it was limited to the seventh to
twelfth years in girls and the seventh to fifteenth
years in boys. He stated that the most exact
universally applicable method of equalization of
leg length was operative shortening of the sound
extremity.

Howorth,10 in 1942, described his operation for
femoral shortening. An osteotomy was carried
out in the mid-shaft of the femur by making drill
holes to step-cut the bone. Separation was com-
pleted with an osteotome. The required amount
of bone was removed, and a bone plate was
applied to the shaft of the femur securing the
fragments. A double hip spica cast was worn
three months postoperatively, depending on heal-
ing.

Blount,11 in 1943, in discussing the use of his
blade-plate for internal fixation of high femoral
osteotomies, mentioned use of the plate for in-
ternal fixation after femoral shortening. A Blount
plate with a single angle was placed in the neck
of the femur, and a screw was inserted through
the proximal hole of the plate into the sub-
trochanteric region of the bone. Osteotomy was
performed distally to the screw, and the required
length of bone was removed from the femoral
shaft. The bone ends were approximated and
additional screws placed through the plate for
fixation.

In 1947, Moore12 described a method of short-
ening through the supracondylar region of the
femur. He noted that, in published reports, the
usual site of election for this procedure was the
diaphysis. He felt that the maximum correction
advisable was about 3 in. and that shortening
in excess of this amount tended to produce per-
manent quadriceps weakness. Moore used a
lateral approach to the distal end of the femur
and sectioned the bone with a Gigli saw just
above the condyles. The shaft of the femur was
displaced outwardly, and a proximal osteotomy
with a Gigli saw was carried out, removing the
required length of bone. The resected segment
was divided longitudinally into several parts with
a motor saw, and one fragment was used as an
intramedullary graft between the femoral cond-

yles and the shaft. The graft was inserted first
into the proximal shaft of the bone and secured
with a single transfixion screw passing through
both cortices and the graft. The protruding end
of the graft was then introduced into the meta-
physis and likewise secured with a transfixion
screw. The remaining bone segments were used
as onlay grafts across the osteotomy site. Post-
operative immobilization was maintained in a
single hip spica cast. The author noted that the
longest period of postoperative immobilization
required was sixteen and one-half weeks in his
series of 15 cases. The average period of im-
mobilization was ten weeks, and weightbearing
with support was begun in the cast six to eight
weeks after operation. In all of his patients,
quadriceps power returned to normal soon after
removal of the cast, and no permanent quadri-
ceps weakness occurred.

Thornton,13 in 1949, described a method of
subtrochanteric femoral shortening. The upper
third of the shaft of the femur and the trochanter
were exposed by a lateral incision, and a Smith-
Petersen nail was placed in the neck and head of
the bone. Osteotomy was performed in the sub-
trochanteric region. A flange of bone was left
extending down along the medial cortex of the
proximal fragment. The required length of bone
was then removed from the distal fragment, the
fragments of bone were brought into apposition,
and a plate was attached to the Smith-Petersen
nail. This was fastened to the femoral shaft be-
low the osteotomy with screws penetrating both
cortices. No external fixation was used postoper-
atively.

White, in discussing Thornton’s procedure,
made a plea for shortening the middle third of
the femur, noting that in 5 of 6 subtrochanteric
shortenings which he had performed, 2 resulted
in delayed union and 1 in nonunion. When he
performed femoral shortening in the middle third
of the bone, no delayed unions or nonunions oc-
curred. J. Albert Key stated, “I have used the
subtrochanteric method and I do not like it very
well.”

In 1951, Eyre-Brook14 described his operative
technic, which was essentially the same as that
described by White except that transfixion screws
instead of metal pins were placed transversely
through the overriding fragments. He noted that
in one of his patients, the leg was shortened 4
in. and normal quadriceps power maintained.

In 1954. Thompson and associates15 compared
results and complications of femoral shortening
by means of oblique osteotomy with screw fixa-
tion and transverse osteotomy with intramedull-
arv nail fixation. The former consisted of placing

2

THE JOURNAL-LANCET

a long osteotomy obliquely through the mid-third
of the femoral shaft. The line of osteotomy was
marked with numerous drill holes, and the oper-
ation was completed with an osteotome. The
distal and proximal spikes were then overlapped
to produce the desired amount of shortening, and
the protruding ends were removed. A fracture
clamp was used to hold the bone ends in apposi-
tion, while 4 transverse screws were placed in
staggered relationship to each other for fixation.
Postoperatively, a single hip spica cast was ap-
plied or the extremity was suspended in a
Thomas splint.

In shortening the femur by transverse osteo-
tomy, Thompson removed the required segment
of bone by making 2 transverse cuts through the
mid-shaft. A Kuntscher nail was then placed in-
tramedullarly to secure the fragments. A staple
was driven across the osteotomy site in several
cases to prevent distraction of the fragments.
The fragment of bone removed during the osteo-
tomy was cut into longitudinal segments and
placed across the osteotomy site as a bone graft.
Thompson concluded from a study of his 2 series
of cases that secure internal fixation was not
provided by intramedullary Kuntscher nail fix-
ation alone. He suggested the use of staples
across the bone ends to prevent distraction of the
fragments. He felt that transverse osteotomv of
the femur with intramedullary fixation was not
a simple procedure and one often attended by
serious complications. As oblique osteotomy with
screw fixation was uniformly successful in his
hands, he preferred this method.

In 1955, Jones"5 described a method of femoral
shortening by “oblique-step” osteotomv and in-
tramedullary fixation. With this operation, the
author attempted to avoid one of the complica-
tions noted by Thompson— distraction of the frag-
ments after osteotomy and intramedullary nail-
ing. He shaped an oblique-step osteotomv so
that the distal end of the proximal fragment and
the proximal end of the distal fragment were
wider than the radius of the shaft of the femur.
The plane of each step then inclined away from
the midline proximally on the proximal fragment
and distallv on the distal fragment to become
slightly less in width than the radius of the shaft.
The two projecting segments locked with each
other when placed together and were held by an
intramedullary femoral nail. No screws were
used, and distraction was prevented by the inter-
locking of the oblique-step projections.

INDICATIONS FOB FEMORAL SHORTENING

Surgical shortening of an extremity is not con-
sidered unless the discrepancy in length is great-

er than 1 in. By tilting the pelvis, a person of
average stature can compensate for shortening
of /2 or of an inch. Inequalities of 1 or 1)1 in.
can readily be corrected by lifting the heel of
one shoe and dropping the opposite heel. Minor
shoe corrections such as these are not readily
noticeable either to the patient or to others.
When the discrepancy in length approaches 1/2
in., however, the patient frequently prefers sur-
gical shortening to a shoe with a built-up sole
and heel of an inch or more.

There are many causes of unequal leg lengths.
Fractures occasionally heal with overriding of
the fragments, producing shortening, or the epi-
physial line may be involved, creating an arrest
of growth. Bone infections, including pyogenic
osteomyelitis, tuberculosis, variola, or syphilis
may produce either relative lengthening of the
involved bone or shortening of the extremity.
Bone tumors may be responsible for differentials
in extremity growth. Neurofibromatosis is fre-
quently attended by enlargement in breadth and
increase in length of an extremity. Congenital
abnormalities, including arteriovenous aneurysms
and congenital absence or malformations of bone,
contribute to variations in leg length. Residuals
of poliomyelitis frequently produce a differential
in the rate of growth of the lower extremities.
Prolonged cast immobilization in growing child-
ren may contribute to a slowing of the growth
of the immobilized extremity.

An inequality of 2 in. or more prevents the
patient from standing with the legs together un-
less the hip and knee are flexed on the long side
and interferes considerably with normal activi-
ties, such as walking, running, sports, and danc-
ing. Howorth noted that his patients desired leg
shortening because of limp, the necessity of
wearing a raised shoe and the associated asym-
metric and undesirable appearance of the foot
and leg. Pain was an unimportant factor. Par-
tial disability in walking, running, working and
playing was present in most of his patients. He
noted that the long leg was usually completely
sound except for occasional minor involvement
in patients whose opposite leg was short as a
result of poliomyelitis.

OPERATIVE LENGTHENING VERSUS SHORTENING

When studying the problem of equalization of
leg length, the first inclination is to correct the
deformity by lengthening the short extremity.
By doing so, the involved rather than the normal
extremity is operated upon, and the patient re-
tains his height. However, because of numerous
complications following leg lengthening proced-
ures, the trend at present is to approach the

JANUARY 1958

3

problem by the less dramatic but safer procedure
of femoral shortening. As noted by White, in
patients with lower extremities differing enough
in length to necessitate an operative procedure,
the short limb is almost invariably sufficiently
involved with atrophic muscles so that further
stretching by a lengthening procedure would
result in inadequate function. Complications of
lengthening include nonunion, postoperative in-
fection, and traction damage to nerves, vessels,
and museles which frequently residt in postoper-
ative deformities of the extremity.

Abbott and Saunders,17 who worked extensive-
ly with the problem of bone lengthening, wrote
in 1939: “We emphasize that the procedure of
bone lengthening is, and in all probability always
will be, a major operation with the possibility
of serious complications.”

A well-founded criticism of femoral shortening
is the fact that the well leg is jeopardized. Be-
side the aesthetic reaction against reducing
height, the possibility of surgical sepsis exists.
However, if this fear on the part of the surgeon
is great, as pointed out by White, shortening of
the long leg should not be attempted.

COMPLICATIONS

Thompson has discussed in detail the complica-
tions following operative shortening of the femur
with intramedullary nail fixation. In his series of
11 patients, 5 operative complications occurred.
In 3 of the patients, the nail was too tight, while
in 2, it was too loose. Fragmentation of the
osteotomy site occurred in 1 patient. This was
regarded as unfortunate because of the possibil-
ity of shortening the leg more than anticipated.
In 2 patients, difficulty was experienced in plac-
ing the intramedullary nail. In 1 instance, the
nail became wedged in the distal fragment of
the femur leaving an excessively long portion of
nail protruding above the greater trochanter. In
another instance, the nail impacted and broke
above the greater trochanter when continued
attempts were made to drive it against resistance.

In 2 patients, the Kuntscher nail fit too looselv
in the medullary canal. Staples were used to
bridge the osteotomy site in 1 of them, and union
occurred without complication. However, in
the other, distraction of the femur occurred, re-
quiring a secondary stapling operation three
weeks later.

Fourteen postoperative complications occurred
in the 11 femoral shortenings performed by
Thompson. These included painful irritation
produced by the proximal tip of the nail at the
greater trochanter; severe and disabling gluteal
pain with sciatica, which was relieved by removal

of the Kuntscher nail; angular deformity caused
bv bending of the nail one month postoperative-
ly; and fracture of the nail.

Genu recurvatum occurred in 4 of Thompson’s
patients after Kuntscher nail fixation. In 3 of
these patients, the femur had been shortened 5
cm. or more. The genu recurvatum persisted in
3 patients from one to five months and in the
fourth for two years. Thompson noted that this
complication had not occurred in patients in
whom femoral shortening had been carried out
by oblique osteotomy and felt that the deformity
was produced by temporary partial loss of muscle
tone in the thigh.

Thompson also noted that secure healing as
demonstrated by x-ray examination seemed to be
obtained more rapidly in patients treated bv
oblique osteotomy than in those in whom fixation
was accomplished by means of an intramedullarv
nail. Although abundant peripheral callus ap-
peared early in patients treated by transverse
osteotomy and Kuntscher nailing, obliteration of
the osteotomy site did not occur until eight to
ten months postoperatively. In patients in whom
oblique osteotomy was performed, union usually
was complete by the end of the fourth month.

TECHNIC

The desired length of bone to be removed is
determined by clinical measurement of the lower
extremities between the anterior superior iliac
spines and the medial malleoli. The patient is
placed upon the operating table in the supine
position, and the limb is draped to expose the
thigh and the region of the greater trochanter.
Using Henry’s18 technic, an anterolateral incision
is made. The rectus femoris muscle is retracted
medially and the vastus lateralis laterally to ex-
pose the vastus intermedins, which is split longi-
tudinally and reflected subperiosteally from the
femoral shaft. A series of longitudinal drill holes
are made through the mid-shaft of the femur,
passing in an anteroposterior direction through
the anterior and posterior cortices of the bone.
These holes are placed in a Z-shaped configura-
tion to outline a step-cut osteotomv. The longi-
tudinal length of the osteotomv is twice the
length of the desired amount of bone to be re-
moved. The drill holes are then connected bv
means of a sharp osteotome, using care to avoid
splintering or splitting the femoral shaft. The
desired length of bone is then removed from
each of the proximal and distal fragments with
a motor saw.

A Kuntscher cloverleaf nail is used for intra-
medullary fixation of the bone. A guide pin is
first introduced into the medullary canal of the

4

THE JOURNAL-LANCET

j proximal fragment and directed proximad to
emerge above the greater trochanter through the
skin of the buttock. The thigh is adducted and
flexed at the hip during introduction of the guide
pin in order to place the point of emergence on
the buttock as close to the greater trochanter
laterally as possible. The proper length of nail
i is determined preoperatively by clinical measure-
ment of the extremity, and the diameter of the
pin is determined during the operative procedure
by introducing nails of various sizes into the med-
ullary canal of the femur. The nail should fit
snugly within the medullary canal but should not
be so great in diameter that the femoral shaft is
split during its insertion. The proper diameter
can be judged by striking the nail with a mallet
and noting its progress into the bone. A nail of
proper diameter will advance 3 to 4 mm. with
each mallet stroke. After the proper sized nail
has been chosen, it is introduced along the guide
pin into the proximal fragment of the femur so
that it is just visible at the osteotomy site. The
femur fragments are then reduced and held with
a bone clamp while the nail is driven into the
distal fragment. X-rays are made on the operat-
ing table in both the anteroposterior and lateral
planes. Films of sufficient size are used so that
the knee joint is visualized to determine the posi-
tion of the distal end of the intramedullary nail.
Two metal screws are then placed transversely
across the step-cut osteotomy to prevent distrac-
tion of the bone fragments. In preparing the
drill holes for the screws, the intramedullary nail
must be missed with the drill point. Sufficient
cortex is present, however, to provide secure
fixation of the fragments with the screws.

Postoperatively, the patient is kept at bed rest
until quadriceps strength is sufficient for active
straight leg raising. He is then allowed to be-
come ambulatory on crutches and instructed to
walk in normal fashion, placing approximately
the weight of the shortened extremity on the
floor. Two to three months postoperatively, if
x-ray examination reveals sufficient callus for-
mation, the crutch on the operated side is dis-
carded. The intramedullary nail is removed in
one and one-half to two years, when the osteo-
tomy site is shown to be completely crossed by
normal bone trabeculae on x-ray examination.

CASE REPORT

J.L.R., age 6, was examined at a crippled children’s
clinic May 8, 1948, by another orthopedist. Examina-
tion revealed a waddling gait, a bilateral positive Tren-
delenburg test, and limited abduction of both hips. A
roentgenogram of the pelvis disclosed bilateral congenital
dislocation of the hips.

She was admitted to Trinity Hospital June 28, 1948,

where Kirschner wires were placed through the supra-
condylar regions of both femurs, and skeletal traction
was applied until August 10, 1948, when the right hip
was exposed through a Smith-Petersen incision. The
capsule of the joint was found to be markedly thickened
and the neck of the femur shortened and anteverted.
The head of the bone was somewhat flattened and the
acetabulum was shallow and filled with fibrous tissue
which was excised. The ligamentum teres appeared
rudimentary. The head of the femur was reduced into
the acetabulum and a rim of bone turned down with a
curved chisel from the ilium, including the upper aceta-
bular rim. Bone was removed from the wing of the
ilium and placed as a wedge above the shelf. A hip
spica cast was applied postoperatively. Skeletal traction
was continued on the left lower extremity until Septem-
ber 30, 1948, when the left hip was operated upon. The
head of the femur was found to lie above the acetabulum,
which was also filled with fibrous and fatty tissue and
excised. The hip was then easily reduced and was
moderately stable. A shelf was turned down from above
the acetabulum, including the acetabular rim, and bone
was taken from the ilium above to form a wedge above
the shelf. A bilateral subcutaneous adductor tenotomy
was also done. A single hip spica cast was applied post-
operatively. The patient was discharged from the hospit-
al December 21, 1948, on crutches.

On February 25, 1949, she was readmitted to the
hospital for physiotherapy and instruction in gait. She
was able to walk fairly well when discharged April 18,
1949. She had a negative Trendelenburg test bilaterally,
but some internal rotation of both lower extremities
and adduction of the right thigh were present. She re-
turned to the hospital July 15, 1949, for a supracondylar
rotation osteotomy of the left femur.

Examination November 1, 1949, demonstrated that
she walked with both feet pointing forward, had negative
Trendelenburg tests bilaterally, and the hips felt stable.

The patient was seen about once yearly bv various

Fig. 1. Roentgenogram of pelvis June 19, 1956, eight
years after bilateral open reduction and shelf operations
for congenital dislocated hips. Shelf on the left has ab-
sorbed, but both hips remain in acetabula and range of
motion is excellent.

JANUARY 1958

5

Fig. 2. Roentgeno-
gram of left femur
August 5 , 1957,
seven weeks after
shortening and fix-
ation with intra-
medullary nail.
Transverse screws
prevent distraction.

orthopedists at crippled children’s clinics from 1949 to
1957. During this time, a gradual relative discrepancy
between the length of the lower extremities was noted.
WHen examined June 19, 1956, leg length was found
to be 3154 in. on the right and 3354 in. on the left. It was
further noted that she walked with a slight right hip
limp and that the Trendelenburg test was negative on
the left but slightly positive on the right. Motion in
both hips was excellent. An x-ray of the pelvis ( figure
1 ) revealed that the hips were seated within the aeeta-
bula. A good shelf was present on the right. The head
of the right femur was somewhat flattened, and the neck
was somewhat shortened. The shelf on the left had
absorbed. She was advised to wear a 1-in. lift on her
right sole and heel, and the possibility of shortening the
left femur was discussed.

She was next seen May 1, 1957, at a crippled chil-
dren’s clinic by another orthopedist. He noted that the
right lower extremity remained 2 in. short and discussed
femoral shortening with the family as the patient was not
wearing a shoe lift for “social reasons.”

The girl returned to the Northwest Clinic, June 17.
1957, at the age of 15 years. Leg length now was 3154

in. on the right and 3354 in. on the. left. On June 18,
1957, she was admitted to the hospital for shortening o.
the left femur. A step-cut osteotomy was made in the
mid-shaft of the femur using a motor drill and an osteo-
tome. The length of the longitudinal limb of the osteo-
tomy was 3 in. to produce 1 54 in. of shortening. One and
one-half inches were removed from both the proximal and
distal fragments of the femur, and the bone fragments
were reduced and held with a bone clamp while a Kunt-
scher cloverleaf intramedullary nail was inserted. Two
metal screws were placed transversely across the tongues
of the osteotomy. Postoperative reeoverv was unevent-
ful. Physiotherapy was started postoperatively and by
July 10 she was able to actively lift her left leg when
lying in the supine position, and ambulation on crutches
was begun. She was discharged from the hospital
July 14.

She was last seen in the office August 5, 1957, walking
well with two crutches. Leg length measured from the
anteriorsuperior spine to the medial malleolus was 31 in.
on the right and 3154 in. on the left. Measurements from
the anterior spine to the upper pole of the patella were
15 in. on the right and 1554 in. on the left. A roentgeno-
gram of the left femur (figure 2) revealed that the frac-
ture fragments and the metal fixation had remained in
satisfactory position and alignment with good callus
formation. She was advised to place about 25 per cent
of her weight on her left leg and to discontinue the left
crutch in about six weeks.

SUMMARY

Femoral shortening is an accepted method of
equalization of leg length after the individual is
past the age when epiphysial arrest is effective.
The advantages of intramedullary fixation can
be utilized if proper selection of nail size is made
and distraction is prevented by internal fixation.

A case report is presented in which step-cut
osteotomy and intramedullary nailing are com-
bined with simple screw transfixion for fixation
and prevention of distraction. The literature of
femoral shortening is reviewed.

REFERENCES

1. Phemistfr, D. B.: Operative arrestment of longitudinal

growth of hones in treatment of deformities. T- Bone & Joint
Surg. 15:1, 1933.

2. Steindler, A.: A Textbook of Operative Orthopedics. New
York: D. Appleton & Co., 1925, p. 174.

3. Glaessner, P.: Die Kontinnitatsresektion der langen Rohren-
knochen zur Ausgleichung von Verkurzungen. Ztschr. Orthop.
30:39, 1908.

4. Deutschlander, K.: Die funktionelle Bedeutung des Langeu-
ausgleiches nach Heine. Ztschr. Orthop. 51:64, 1929.

5. Shands, A. R.: Shortening the long leg. Internat. 1. Surg.
30:273, 1917.

6. Fassett, F. L.: Inquiry into the practicability of equalizing

unequal legs by operation. Am. J. Orthop. Surg. 16:277, 1918.

7. Royle, N. D.: Treatment of inequality of length in lower

limbs. M. J. Australia 1:716, 1923.

8. White, J. W.: Femoral shortening for equalization of leg
length. J. Bone & Joint Surg. 17:597, 1935.

9. Harmon, P. H., and Krigsten, W. M.: Surgical treatment

of unequal leg length. Surg., Gynec. & Obst. 71:482, 1940.

10. Howorth, M. B.: Leg shortening operation for equalizing

leg length. Arch. Surg. 44:543-555, March, 1942.

11. Blount, W. P.: Blade-plate internal fixation for high femoral
osteotomies. J. Bone & Joint Surg. 25:319, 1943.

12. Moore, R. D.: Supracondylar shortening of femur for leg
length inequality. Surg., Gynec. & Obst. 84:1087, 1947.

13. Thornton, L.: Method of subtrochanteric limb shortening. J.
Bone & Joint Surg. 31A:81, 1949.

14. Eyre-Brook, A. L.: Bone-shortening for inequality of leg
lengths. Brit. M. J. 1:222, 1951.

15. Thompson, T. C., Straub, L. R.. and Campbell. R. D.:
Evaluation of femoral shortening with intramedullary nailing.
J. Bone & Joint Surg. 36A:43, 1954.

16. Jones, K. G.: Femoral shortening by “oblique-step” osteotomy
and intramedullary fixation. J. Bone & Joint Surg. 37 A: 575,
1955.

17. Abbott, L. C., and Saunders, J. B. deC. M.: Operative
lengthening of tibia and fibula; preliminary report on further
development of principle and technic. Ann. Surg. 110:961,
1939.

18. Henry, A. K.: Extensile Exposure Applied to Limb Surgery.
Baltimore: Williams & Wilkens Co., 1954.

6

THE JOURNAL-LANCET

Angina Pectoris Treated by Relaxation and
Automatic Attentive Respiration

AARON FRIEDELL, M.D.

Minneapolis, Minnesota

Twenty-one patients in whom angina pec-
toris developed after severe coronary dis-
ease and/or eoronarv thrombosis were followed
carefully between the years 1925 and 1955. Sat-
isfactory results were obtained by teaching them
simple methods of relaxation, mild light physical
exercises, and, most important, automatic at-
tentive diaphragmatic breathing at stated rest
periods three to four times daily with a natural
pause between the respiratory functions.

Of these 21 patients, 12 are living and are
comfortably well. Two died from coronary
thrombosis, and 7 died from other than cardiac
causes. But, all of them were free from pain at
least for more than two years after they learned
the technic of automatic relaxed diaphragmatic
breathing. One was under care for over thirtv
years, and he was presented before several medi-
cal groups to demonstrate the method and ration-
ale of breathing. His death was caused by an
accident after the Christmas holidays in 1955.

This case of H. R. was reported before in
1948. 1 To briefly summarize it, this patient had
an acute myocardial infarction in 1924. He came
under medical care one year later in September
of 1925 with symptoms of angina pectoris, from
which he had obtained relief bv taking nitro-
glvcerin sublingually.

He was taught the method of relaxation and
automatic attentive breathing. He gradually
showed improvement and was symptom-free and
normally active until the day of his sudden death.
He had not needed nitroglycerin nor had he been
confined with any major ailment for twentv-eight
years. His electrocardiograms were always ab-
normal ( figure 1 ) .

The pathologist. Dr. S. T. Nerenberg, stated
in H.R.’s autopsy report: “The main left coronary
artery and descending branch show severe in-
timal arteriosclerosis. The circumflex branch and
right coronary vessels show only mild to moder-
ate intimal arteriosclerosis. On opening into the
cardiac chambers, the left side of the heart is

aaron friedell is on the staffs of Mount Sinai and
Asbunj Methodist hospitals, Minneapolis.

seen to be moderately dilated. The left ventri-
cular wall is hypertrophied. The heart weighs
500 gm. The valves are all grossly normal in
appearance. The right side is not remarkable.”

During the last thirty years of his life, this
patient had spent ten minutes or more two to
three times a day performing this relaxation and
breathing exercise, apparently with good results.

This presentation will not analyze the age and
sex of the 21 patients nor will etiology be dis-
cussed. Two subjects will be presented: (1) the
technic that was used and ( 2 ) the rationale most
likely to produce satisfactory results.

TECHNIC

If an angina pectoris patient was on any medica-
tion when we started our training, he was ad-
vised to continue temporarily. However, the
chief aim has been to reduce the physical and
mental tension and effort. The patient was told
to: “Put yourself at ease at the first appearance
of pain. Bring to mind some pleasant thought
and then relax your entire body. Keep the lips
closed but teeth slightly apart, and, if necessary,
put the tongue somewhat between the teeth so
as to keep them apart, which helps to keep the
jaw and facial muscles relaxed. Then, with the
rest of the body in a state of relaxation, turn the
attention to slow diaphragmatic breathing. Slow
down the breathing without effort, make breath-
ing effortless. Bring the breathing rate down to
6 per minute or less and at ease.”

Some of these patients could breathe at a rate
of only 2 per minute ( figure 2 ) for ten to fifteen
minutes or longer and then feel completely re-
laxed.

Patients were instructed to cultivate effortless
breathing with a pause after inhalation and after
exhalation. The pauses between respirations were
extremely important to our observations, and
that phase will be discussed later.

RATIONALE FOR TREATMENT

1. When the body musculature is at ease, the
oxygen demand is greatly reduced.

Krogh2 called attention in his book, Anatomy

JANUARY 1958

7

Fig. 1. Abnormal electrocardiogram and yet patient folly active and comfortable.

and Physiology of Capillaries, that at rest the
body musculature needs only 1/15, and could
be as low as 1/30, of the oxygen that is required
during marked activity.

Best and Taylor5 showed that slow deep
breathing affords a better oxygen supply than
fast shallow breathing. Thus relaxation and auto-
matic attentive breathing afford a reduced de-
mand and increased supply of oxygen.

2. Slow diaphragmatic breathing reduces card-
iac effort. During inhalation, the lungs widen
and lengthen. According to Macklin,4 the pul-
monary vasculature both lengthens and widens.
So, while blood accumulates in the pulmonary
vessels during inhalation, less blood is returned
to the left side of the heart. Then, too, during
a deep inhalation as the lungs are distended, the
superior vena cava and the subclavian veins are
compressed between the distended upper lobes
of the lungs and the first ribs.5 These vessels are

compressed, and blood is not returned to the
right heart during the latter half of a deep in-
halation. Similarly, the inferior vena cava is verv
easilv compressed between the diaphragm and
the posterior edge of the liver.6 After all, the
pressure in the veins, both superior and inferior
vena cava, is very low— only about 8 to 15 mm. of
Hg. The veins are soft as compared to the arter-
ies, and not much pressure is required to shut
off the return of blood to the right heart. Thus,
during deep inhalation, less blood is returned
both to the left heart and to the right heart. And.
the heart gets a reduced work load after about
the third pulse beat.6

Bearing in mind that the pulsations during the
time of deep inspiration mean less work for the
left heart, we can simplify the explanation for the
benefits derived by taking for an example person
A with a pulse rate of 80 per minute and a res-
pirators' rate of 20 and compare him with person

8

THE JOURNAL-LANCET

Fig. 2. Respiration chart il-
lustrating an automatic res-
piratory rate of less than 3
per minute.

B, whose pulse rate is 80 but whose respiratory
rate is only 4. Then, of course, person A would
have 20 inspirations and 20 expirations which
means 40 actions during that minute of 80 pulse
beats. Dividing 80 by 40 gives us 2 pulse beats
during an inspiration. However, if person B
breathes only 4 times per minute, that means he
has 8 actions— 4 inspirations and 4 expirations—
and dividing 80 bv 8 gives us 10 pulse beats per
minute or 7 pulsations for reduced left heart
effort. That could mean a reduced oxygen de-
mand for the cardiac musculature.

a 80 0 „ 80 1A

A- 40 8 ~ 1

3. Breathing affects the acid-alkaline relation-
ship in the blood and in the other body fluids
and tissues as well.7 Normally, the pH of the
blood is about 7.4 but it shifts with respiration,
7.35 on inhalation and 7.45 on exhalation. That
shift takes place at the usual respiratory rate of
16 to 20 per minute. However, if the respiratoiy
rate is markedly slowed up, the pH shift will be
greater, since, during inspiration, C02 is retained
and increases the hvdrogen ion concentration in
the blood.7 And, since the hydrogen ion has a
very rapid diffusion rate, it affects all other tis-
sues as well.3 So, a definitelv slowed-up respira-
tory rate may well affect the body, possibly
through the Krebs cycle,8 wherever it functions
in the body tissues.

4. I woidd also like to call attention to the
action of the hemoglobin-oxygen pump.9 For, as
the blood flows through the capillaries in the
alveoli of the lungs, the carbon dioxide is de-
livered and flows into the alveolus. On the other
hand, the oxvgen that is present in the alveolus is

absorbed by the hemoglobin and is carried into
the circulations. The carbon dioxide comes into
the alveolus where, if the alveolus is contracting
and ventilating, it is only pushed upward. Other-
wise, since the COL. molecule is heavier than the
02 molecule, it remains and is accumulated in
the alveolus and also in the terminal bronchus,10
and its concentration increases with the increas-
ing pause following an inhalation and exhalation.
While the carbon dioxide content in the air is
only .04 per cent, in the alveoli, it is a little better
than 4 per cent, depending upon the rate of res-
piration. If respiration is slow with a lengthened
pause, then the concentration of 0O2 in the al-
veoli and terminal bronchi is much greater. If
respiration is very slow, the concentration of
C02 may be better than 8 per cent.10 A concen-
tration of COL. of 8 per cent or more has anesthe-
tic qualities and contributes valuably to the
acetvlcholine cycle.11

Gesell and associates11 have shown that the
acetylcholine production in the lungs can be in-
creased fivefold or more with an increase of C02,
since C02 checks the action of cholinesterase
which destroys acetylcholine. So, if respiration
is slowed up to 6 per minute or less, the amount
of C02 in the alveoli and terminal bronchi is
increased and the acetylcholine function is im-
proved. Acetylcholine also has a very marked
permeability rate and even though it is short
lived due to the ubiquitous cholinesterase of the
tissue, in the presence of an increased CO_> con-
centration, its life cycle is longer.1 That, too,
very likely improves the function of the coronary
blood flow by its vasodilator action. Therefore,
slow, automatic, deep diaphragmatic breathing

JANUARY 1958

9

at a rate of 6 per minute or less with a pause be-
tween both inhalation and exhalation can be a
valuable adjunct in the treatment of angina pec-
toris.

5. One may speculate also that with a breath-
ing rate reduced to 6 or less per minute and with
a lengthened and more effective inhalation per-
iod, the diastoles, which take place during such
inhalations, afford a greater gradient of systemic
pressure12-15 in the right auricle than in the left

REFERENCES

1. Friedell, A.: Automatic attentive breathing in angina pec-

toris. Minnesota Med. 31:875, 1948.

2. Krogh, A.: The Anatomy and Physiology of Capillaries. New
Haven: Yale University Press, 1930, p. 57 and 158-159.

3. Best, C. H., and Taylor, N. B.: Physiological Basis of Med-
ical Practice, ed. 3. Baltimore: Williams and Wilkins Co.,
1945, p. 527.

4. Macklin, C. C.: Evidences of increase in capacity of pul-

monary arteries and veins of cats, dogs, and rabbits during
inflation of freshly excised lungs. Rev. Canad. de biol.
5:199, 1946.

5. Candel, S., and Ehrlich, D. E.: Venous blood flow during
valsalva experiment including some clinical applications. Am.
J. Med. 15:307, 1953.

6. Edholm, O. G.: Peripheral circulation. Ann. Rev. Physiol.

12:311, 1950.

7. VanSlyke, D. D.: Acidosis and alkalosis. Bull. New York

Acad. Med. 10:103-137, 1934.

8. Soskin, S., and Rachmiel, L.: Carbohydrate Metabolism,

revised edition. Chicago: University of Chicago Press, 1952,
P. 57.

ventricle. Since during diastole, the pressure in
the left ventricle is supposed to be zero, diastole
at a very slow breathing rate may well provide
an opportunity to call the thebesian and luminal
vasculature into play and, perhaps, improve the
collateral coronary circulation.13,16

In summary, an additional report is made on
automatic attentive breathing and relaxation as
a valuable adjunct in the treatment of angina
pectoris.

9. Draper, W. B., and Whitehead, R. W.: Phenomenon of

diffusion respiration. 28:307, 1949.

10. DuBois, A. B., Fenn, W. O., Fowler, R. C., and Soffer,

A.: Alveolar COo measured by expiration into the rapid in-

frared gas analyzer. J. Appl. Physiol. 4:526, 1952.

11. Gesell, R., Mason, A., and Brassfield, C. R.: Acid hu-

moral control of heart beat. Am. J. Physiol. 141:312, 1944.

12. Gregg, D. E.: Coronary circulation. Physiol. Rev. 26:28,

1946.

13. Lauson, H. D., Bloomfield, R. A., and Cournand, A.:
Influence of respiration on circulation in man. Am. J. Med.
1:315, 1946.

14. MacCanon, D. M., and Horvath, S. M.: Influence of res-

piration on arterial, and right and left ventricular pressures.
Am. J. Physiol. 168:612, 1952.

15. Seely, R. D.: Dynamic effect of inspiration on simultaneous

stroke volumes of right and left ventricles. Am. J. Physiol.
154:273, 1948.

16. Mautz, F. R., and Gregg, D. E.: Dynamics of collateral

circulation following chronic occlusion of coronary arteries.
Proc. Soc. Exper. Biol. & Med. 36:797, 1937.

Hematemesis, melena, or shock is often the first manifestation of acute ulcer-
ation of the gastrointestinal tract which may occur as a result of stress after
cardiac surgerv. These lesions often arise without previous ulceration and
without premonitory symptoms; hemorrhage, perforation, and death mav ensue.
Patients who have responded abnormally to stress in the past appear prone to
stress ulcers. However, this complication cannot be predicted with accuracy.

The abdomen, as well as the heart and lungs, should be examined frequently
after cardiac operations. Sometimes, rectal examination may be advisable to
detect melena. The physician should be alert to the possibility of acute ulcer-
ation in any patient whose progress is not normal after an operation on the
heart.

Immediate transfusion and earlv surgery may he lifesaving. Abdominal ex-
ploration should not he deferred simply because the patient has recently had
a cardiac operation.

Of 7 patients with acute peptic ulceration after cardiac surgery, 4 died and
1 had emergency gastric resection.

Donald Berkowitz, M. D., Bernard M. Wagner, M.D., and Joseph F. Uricchio, M.D.,
Hahnemann Medical College and Bailey Thoracic Clinic, Philadelphia. Ann. Int. Med. 46:1015-
1023, 1957.

10

THE JOURNAL-LANCET

The Diagnostic Value of
Various Ocular Symptoms

ROBERT W. HOLLENHORST, M.D.
Rochester, Minnesota

Many ocular symptoms are so characteristic
that diagnosis may be made solely from the
history. Others are sufficiently suggestive to per-
mit a minimum of delay in proving the diagnosis.
Still other symptoms of organic ocular disease
enable the alert physician to make the correct
diagnosis even though the eyes may be normal
at the time of examination. The discussion that
follows concerns, for the most part, such char-
acteristic complaints and omits those of lesser
diagnostic value.

As the eye is primarily an organ of sight, it is
plain that the major, most frequent, and most
varied complaints are those pertaining to distur-
bances of vision which may occur in one or both
eyes. This paper will center chiefly around var-
ious disturbances of sight and pain, as nearly all
other ocular symptoms are accompanied by rath-
er obvious signs.

DISTURBANCES OF VISION

Complaints due to errors of refraction include
the following.

1. Blurring of distant vision only is usually
due to myopia. It is common among children,
although they are almost never aware of this
visual defect unless the school nurse or teacher
discovers it. Such children often unconsciouslv
but efficaciously better their vision by narrowing
the palpebral fissures. In so doing, they wrinkle
up their noses and their eyelids, a characteristic
gesture. Early nuclear cataracts and uncontroll-
ed diabetes often cause progressive myopia, and,
thus, they produce blurred distant vision without
notable decrease of near vision.

2. Blurring of near vision only is due to just
one thing — inadequate accommodation. It is
found: (a) among hyperopes whose far-sighted-
ness is either undercorrected or inadequately
corrected; (b) among patients of the third and

robert w. hollenhorst is with the Section of
Ophthalmology at the Mayo Clinic and assistant
professor of ophthalmology in the Mayo Foundation.

Read at the meeting of the North Dakota State
Medical Association. Fargo, North Dakota, May 27
and 28, 1957.

fourth decades of life who have subnormal ac-
commodative power or premature presbyopia;
(c) among patients in the fifth or older decades
whose presbyopia has become manifest; ( d )
among patients who have developed a temporary
subnormal accommodation while under treat-
ment for hypertension with the ganglion-block-
ing agents; and (e) among patients who have
had atropine, homatropine, cyclopentolate ( Cy-
clogyl), or other cycloplegics instilled into their
eyes or who may be using systemically excessive
amounts of atropine, belladonna, trihexyphenidyl
( Artane), or other antispasmodic agents. Patients
who have internal ophthalmoplegia as a result of
palsy of the third cranial nerve are usually so
disturbed by the resultant diplopia that they do
not complain of being unable to read with the
affected eye.

3. Blurring of both distant and near vision re-
quires complete ophthalmologic examination, as
it may be due to a variety of causes, such as
uncorrected refractive errors, cataract, glaucoma,
or disease of the cornea, vitreous, retina, optic
nerves, or the higher visual pathways.

Intermittent blurring of vision of both eyes
lasting several hours to a day or more may be
caused by diabetes, for fluctuations in the blood -
sugar level cause changes in the density of the
lens and, therefore, produce variations in the
refractive power of the eyes. Sometimes there
may be a difference of as much as 2 or 3 diopters
on successive days. Intermittent loss of vision of
one or both eyes is a very common symptom of
insufficiency of the basilar or carotid artery and
is usually of four or five minutes’ duration. This
svmptom also accompanies the choked disks of
increased intracranial pressure.

An instantaneous loss of vision in one eye
unaccompanied by pain or other symptoms is
probably due to occlusion of the central artery
of the retina. This is especially true if the patient
awakens in the morning with a sightless eye. If
the individual is more than 60 years old, tempo-
ral arteritis should be considered and ruled out
as soon as possible. Half of such patients go
blind in the remaining eye during the next few

JANUARY 1958

11

hours or days. Patients with temporal arteritis
often complain of transient diplopia or amaurosis
fugax several hours prior to the actual permanent
visual loss. The ophthalmoscope may show a
swollen, hazily seen optic disk and, perhaps,
several cotton wool patches in the retina. The
patient may have had tender scalp arteries, an
influenza-like syndrome, and temporal headaches
for the previous several weeks. He frequently
has an ervthrocvte sedimentation rate of more
than 100 mm. in one hour (Westergren method).
Biopsy of the temporal artery usually corrob-
orates the diagnosis. Very high doses of corti-
sone are a specific treatment for temporal arter-
itis and prevent further loss of vision. There is
no good treatment for occlusion of the central
artery, although oxygen and anticoagulant ther-
apy should he started if the patient is seen dur-
ing the first twelve hours.

A moderateh/ rapid loss of vision in one eye
occurring over a few hours to a day is usually
due to one of the following: (1) occlusion of
the central vein, which causes red vision if the
hemorrhage extends anterior to the retina into
the vitreous; (2) acute glaucoma when the visual
loss is accompanied by seeing rainbows around
lights, severe pain, cloudiness of the cornea,
dilatation of the pupil, and redness and hard-
ness of the eye; (3) acute iritis, with moderate
pain, miosis, cloudiness of the aqueous and red-
ness of the eye; and (4) optic neuritis, which
causes pain on moving the eye, more rapid loss
of vision, diminished pupillary reflex, and papil-
ledema. The same symptoms occur with retrobul-
bar neuritis, but the disk then looks normal at
first.

Loss of vision in both eyes, whether rapid or
slow, is caused by bilateral intraocular disease,
lesions of both optic nerves, a lesion of the optic
chiasm, or a lesion of the higher visual pathways
in the cerebrum. Immediate further ophthalmo-
logic and neurologic investigation is indicated.

In addition to losses of vision, such as those
previously described, a host of interesting entop-
tic visual disturbances may bring the patient to
the physician for examination. The patient's de-
scription of most of these disturbances is sufficient
for making the diagnosis on the basis of the
history alone.

The most common disturbances, of course, are
represented by the so-called floaters, spots, or
muscae volitantes. Almost everyone can see
against the background of blue skies, snow, and
bright ceilings the small cobwebby or stringy
threads which always float away when one tries
to look directly at them. These are small rem-
nants of the fetal vascular system or condensa-

tions ol the vitreous and have no pathologic sig-
nificance. Often, a patient who complains of
these disturbances and comes for advice is in
an anxiety state or has another, more severe
psychiatric problem. Such patients frequently
complain also of other entoptic phenomena. They
may be alarmed by the dancing lights that are
seen when the lids are closed over the eyes. Thev
fearfully observe the after-images that are always
present after gazing at bright objects. They often
have learned to prolong the duration of these
images by blinking their eyes slightly from time
to time. Thus, instead of disappearing in a few
seconds, these after-images may persist five min-
utes and longer. Some patients observe the very
interesting entoptic phenomenon in which if a
bright surface, such as the sky, is observed, they
may see a great number of small dancing spots
like electric sparks which shoot up suddenly
along a curved short path and then disappear
as abruptly as they appeared. These are prob-
ably red blood cells going through tiny capil-
laries in the macular portion of the retina.

Another interesting but pathologic visual phe-
nomenon is called “ Moore’s lightning streaks.”
These are seen more frequently by persons in
their fifties, sixties, and seventies but may appear
at any age. They come as sudden, bright, light-
ning flashes in one eye, almost invariably in the
far temporal field. Turning the eyes rapidly,
shaking the head, or, often, merely walking down
a stairway will produce the phenomenon. The
cause is a degenerative shrinkage of the vitreous
of the eye. In attempting to separate from the
contiguous retina, a strand of vitreous tugs and
pulls on the retina and causes the lightning
streaks. The vitreous continues to shrink and
eventually separates completely from the internal
limiting membrane of the retina. When this oc-
curs, the patient notes the advent of several
large floaters in his field of vision, but the light-
ning streaks will have gone and will not return.
During the period in which the lightning streaks
are seen, there is danger the retina may be pulled
oil, especially if a strand of the vitreous tugs on
a cvstic space in the retina. Therefore, such
patients should have a thorough ophthalmoscopic
examination through a widely dilated pupil, us-
ing 2 per cent solution of homatropine hvdrobro-
mide and 10 per cent solution of phenylephrine
( Neo-Synephrine) hydrochloride, to rule out in-
cipient retinal detachment. Sometimes, a small
hole is found without detachment of the retina.
This is, of course, the ideal time to surgically
close such a hole. After the streaks are gone and
the floaters appear, the danger of retinal detach-
ment is probably over.

12

THE JOURNAL-LANCET

A similar but quite different visual phenomenon
is sometimes described as a “lightning streak.”
This is the peculiar and characteristic scintil-
lating scotoma of migraine which takes many
forms. However, careful questioning ordinarily
leaves no doubt as to the diagnosis. The visual
symptoms appear during the aura, supposedly
during the period of vasoconstriction of the cere-
bral vessels. The patient may suddenly see a
bright spot of light a little to one side of the
axis of his vision. The spot begins to expand and
then he notes a loss of part of the letters of words
he tries to read, or he may see only the right
half or the left half of objects he regards with
either eye or with both eyes. The bright area
begins to expand further, and it pulsates at a
rapid rate (computed to be about 10 beats per
second, comparable to the rate of the alpha
rhythm in the electroencephalogram). It may
expand to fill either the same quadrant in each
eye or a whole homonymous half-field, and it
may be brightlv colored. At its maximum, the
whole phenomenon suddenly disappears in a
maelstrom of light. The episode usually lasts at
least ten minutes and sometimes as long as thirty
minutes. Shortly after the aura is over, the head-
ache develops. It usually affects the side of the
head opposite to the visual aura and, therefore,
corresponds to the part of the brain from which
the aura emanated. Sometimes, the visual phe-
nomena may be so-called “fortifications.” These
are figures which look like the top of an ancient
battlement. Other patients may merely see snow-
flakes or dancing twinkling lights or experience
a sensation as of heat waves. Some patients have
a homonymous hemianopsia without scintillating
lights, which may last ten to thirty minutes.
Those who have this phenomenon must be eval-
uated carefullv to be sure an intracranial lesion
is not overlooked. Intermittent insufficiency of
an internal carotid artery or of the vertebral or
basilar arteries may produce a transient homonv-
mous hemianopsia, but never, or almost never,
such scintillating scotomas. Many patients who
have the tvpical visual aura of migraine are
spared the headaches and suffer only the terrify-
ing visual symptoms.

Patients with tumors of the temporal or occipi-
tal lobe sometimes see images or scenes of vari-
ous types. These are quite different from the phe-
nomena that are described by patients who have
ocular migraine, although these phenomena too
may appear for short periods. They may occur
with increasing frequency several times a week
or even daily, in contrast to migraine equivalents
which usually have occurred for years and, ordi-
narily, only once or twice a month.

Patients who have tumors in the parietal
lobes are sometimes bothered by peculiar visual
disturbances which come periodically. These rare
phenomena consist of a confusion of right and
left and, sometimes, of an inversion of the envi-
ronment. Such patients may note that people
seem to be walking on the walls of the room in
a horizontal position rather than on the Hoor.

Micropsia is the term applied to the visual
phenomenon in which objects appear smaller
than they really are. This is commonly due to
spasm of the accommodation and is observed
among patients whose accommodation is partial-
ly paralyzed as in early presbyopia. Voluntary
convergence and concomitant accommodation
produce micropsia. It is sometimes the present-
ing complaint in psychiatric patients. Patients
who have edema of the macula may have this
symptom, although more often they, have meta-
morphopsia.

Macropsia, in which images seem larger than
normal, occurs when there are scars in the retina
and is rarely observed.

Metamorphopsia, the condition in which the
shape of objects is distorted so that a square
looks asymmetric or a circle looks oval or a
straight line appears bent, usually results from a
disturbance of the macula by edema, hemor-
rhage, choroiditis, detachment of the retina, or
other lesions. A hole in the fovea may cause a
straight line to be seen as a bisected or bent line.
Improperly corrected astigmatism may distort
the entire environment so that objects appear
twisted or closer or farther away than they really
are.

Colored vision, so-called chromatopsia, is al-
ways indicative of some type of pathologic proc-
ess. Rainbows seen around artificial lights are
caused by edema of the cornea, as in acute con-
gestiye glaucoma, and sometimes by nuclear
cataracts. Rainbows caused by cataracts are
constant, while those due to glaucoma appear
with a rise of intraocular pressure and disappear
when the pressure becomes normal. Red vision
occurs among patients who have preretinal
hemorrhages or hemorrhage into the vitreous.
Exposure to snow or bright lights, aphakia, iri-
dectomy, or prolonged dilatation of the pupil
may also lead to red vision. Yellow vision mav
be associated with jaundice, santonin poisoning,
or carbon monoxide poisoning. White or blue
vision may be caused by digitalis intoxication;
sometimes objects may appear to be covered
by snow.

Photophobia is a common complaint. Organic
lesions of the eyes cause severe photophobia.
These lesions are always easilv discovered bv

JANUARY 1958

13

examination and consist of albinism, lesions of
the cornea, and inflammatory involvement of the
internal eye. Most people are more comfortable
in bright light if they wear colored glasses. How-
ever, photophobia is often a symptom of severe
psychoneurosis; such individuals seem to find
security behind dark glasses and wear them even
indoors, a form of purdah.

Oscillopsia is an interesting manifestation of
cerebellar or pontine dysfunction. There may be
no visible disturbance of eye movements, al-
though sometimes there is nystagmus. The
patient complains of inability to recognize people
unless he and the person he is attempting to
recognize are stationary. One woman complain-
ed that whenever she walked into a room, she
could not identify any of her friends sitting or
standing until she herself had come to a stand-
still. This phenomenon is usually due to multiple
sclerosis but sometimes to other lesions of the
pons. It has been observed as a toxic effect of
streptomycin on the vestibular nerves. The symp-
toms result from ataxia of the ocular movements
so that the eyes cannot move smoothly from one
point of fixation to another.

Double vision requires complete ophthalmo-
logic and neurologic examination. It indicates
serious intracranial disease as a rule, since it is
due to paresis of one of the extraocular muscles.

Triple or quadruple vision is caused by abnor-
malities in the cornea, lens, or vitreous of one or
both eyes. Diplopia in one eye may have the
same etiologic basis.

Night blindness, in which the individual has
trouble seeing in dim light, is the result of loss
of function of the rod cells in the retina and is
most frequently due to degeneration of the ret-
ina as in retinitis pigmentosa or, more rarelv, to
deficiency of vitamin A.

PAIN

Pain in and about the eyes may come from a
multitude of causes, some due to ocular disease
and others not in any way related to the eyes.
Pain may be unilateral or bilateral. It may be
aching, boring, sharp and stabbing, scratchy,
burning, or itching in character.

A sharp stabbing pain results from a lesion of
the epithelium of the cornea and is often followed
by a scratchy sensation. It is the characteristic
pain of a foreign body on the cornea or lodged
under the upper lid scratching the cornea. The
scratchy sharp pain is accompanied by profuse
laerimation and severe photophobia.

A patient, usually a young married woman,
frequently complains that she is awakened every
night between 2 and 3 a.m. by a sharp, very

severe knife-like pain in one eye. The pain lasts
ten to fifteen minutes and during this time the
eye also feels scratchy. When the pain is gone,
she falls asleep again and has no trouble the rast
of the night. The next morning when she has the
eye examined, the physician finds nothing to ac-
count for her symptoms and passes the episode
off as of no consequence. Such patients some-
times go from physician to physician until finally
one recognizes this sequence of events as the
characteristic symptomatology of recurrent ero-
sion of the cornea. Usually, some weeks or
months before, the eye may have been scratched
by a baby’s fingernail or other foreign body. The
abrasion probably healed promptly. However,
such abraded areas may remain roughened and
the epithelium may not grow securely to the
basement membrane. Thus, when the lids are
closed in sleep, the epithelium of the lid and
that of the cornea may grow together. A slight
movement of the lid in sleep then rips off the
piece of cornea, thus producing the characteristic
chain of events. Duration of the pain is only
ten to fifteen minutes because the wound heals
rapidly. Simply instilling boric acid eye oint-
ment liberally at bedtime for several consecutive
days heals this lesion. Tetracaine (Pontocaine)
drops instilled during the height of the pain pro-
duce immediate relief. Recurrent corneal blebs
may produce similar symptoms.

The so-called ether burn of the cornea, occur-
ring when a patient wakes up from general
anesthesia with a severely painful, scratchy,
photophobic eye, is not an ether burn at all but
an abrasion of the cornea caused bv brushing
the cornea inadvertently or else by allowing the
lids to remain partially open and thus drying and
macerating the cornea. Use of tetracaine (Pon-
tocaine) and a patch relieves pain until the cor-
nea is healed.

Burning of the eyes, aggravated by tobacco
smoke in the air and sometimes accompanied
bv scratchiness and photophobia, is usuallv due
to dry eyes (keratitis sicca). This condition is
often associated with a dry cottony mouth, sour
stomach, constipation, and, usually, with arthri-
tis. It is caused by a systemic alteration in the
production of glandular fluids on the serous sur-
faces of the body. Tear secretion, as tested by
Schirmer’s method of inserting a strip of filter
paper over the lower punctum, will be absent
or minimal in a five-minute test period. Fluores-
cein will stain innumerable minute areas of
epithelial erosion of the corneas, which are vis-
ible only by biomicroscopic examination. The
medication used is artificial tears, an isotonic
solution of methyl cellulose ( Isopto-Alkaline ) ,

14

THE JOURNAL-LANCET

which is effective in 98 per cent of patients. The
other 2 per cent may be helped by using a prep-
aration of their own blood serum made under
sterile conditions.

Itching of the eyes almost invariably denotes
an allergic condition of the eyelids or conjunc-
tivae. Pollens, cosmetics, house dust, and animal
dandruff are the most common causes. Two
diseases of the eylids cause itching: (1) angular
conjunctivitis and (2) vernal conjunctivitis. The
former, an infection of the lids and conjunc-
tivae caused by a diplobacillus, frequently occurs
in aged people and is manifested by a distressing
itching of the lids accompanied by Assuring at
the outer canthi. It responds well to 1/3 per cent
zinc sulfate drops administered four times daily
for about a month. People with vernal conjunc-
tivitis have a well-known way of rubbing their
itching eyes by grinding the heel of the hand into
the orbit. If the examiner everts the upper lids,
he will see large cauliflower-like vegetations of
venial catarrh. Treatment with hydrocortisone
or prednisone drops is effective.

The severe pain of acute glaucoma has been
mentioned. Chronic simple glaucoma does not
usually cause pain in the eyes. The pain of
iritis is much less severe. A patient who has optic
neuritis or retrobulbar neuritis often complains
of pain when the eyes are moved. Scleritis causes
a severe, deep, orbital pain which is aggravated
by turning the eyes. This disease not infre-
quently accompanies rheumatoid arthritis and
may develop in a very severe form in arthritic
patients who have been treated with steroids
for a long time and who have had the hormone
withdrawn too rapidly. The treatment consists of

either systemic or subconjunctival administration
of steroids.

A patient may periodically experience very
severe pain deep in one orbit, which lasts one to
two hours. These attacks usually occur in the
spring and fall and cause excruciating pain
which is generally at its worst during the night.
Each pain rises rapidly to peak intensity and is
accompanied by redness of the eye, lacrimation,
stuffiness of the corresponding side of the nose,
and, sometimes, by constriction of the homo-
lateral pupil. Such a patient, of course, has his-
taminic cephalgia or so-called cluster headaches.

Other types of pain which may be in the
vicinity of the eyes include the scalp pain of
temporal arteritis, the characteristic burning
pain of herpes zoster, and the electric-shock
pains of trigeminal neuralgia. Patients with an
intracranial aneurysm may have severe pains
above one eye accompanied by Horner’s syn-
drome on the same side.

Finally, there is a little known unilateral
orbital pain some people experience when the
nasal mucosa at the ostia of the nasal sinuses
is congested or when the turbinates lie in con-
tact with congested mucosa. Such pain is often
present on awakening, may be aggravated by
consumption of alcohol the night before, and
can be prevented by lying at night with the
painful side of the head turned up. Nasal decon-
gestants often relieve this headache promptly.

Milder forms of pain are occasionally the re-
sult of uncorrected refractive errors and, some-
times, of uncorrected muscle imbalance of a
mild degree. Large amounts of muscle imbal-
ance do not usually cause ocular pain.

Hypoglycemia, with extensor rigidity of the extremities, coma, and acidosis,
can occur as a result of intoxication with Solox, a paint solvent.

Solox, consists principally of methanol and ethvl alcohol and is often ingested
by chronic alcoholics in the southern states. Many persons drink this fluid re-
peatedly with no ill effects. However, occasional patients are hospitalized be-
cause of coma, blurred vision, cramping abdominal pain, or burning of the eyes.

Physical findings include foul breath and chest rales like those of hydrocar-
bon or aspiration pneumonitis. Mania, convulsions, widely dilated pupils,
generalized flaccidity, decreased gag and cough reflexes, loss of deep tendon
reflexes, or extensor rigidity of hvpoglvcemia may be noted.

The carbon dioxide combining power and blood sugar concentration are
low; blood ketones and lactate are increased.

Treatment includes: (1) correction of acidosis by intravenous administration
of 2 per cent sodium bicarbonate solution; (2) reversal of hypoglycemia by
intravenous infusion of hypertonic dextrose at four- to six-hour intervals for
the first twenty-four hours; and (3) supportive care, including antibiotic ther-
apy if aspiration has occurred. Pressor agents may be needed to combat shock.

William J. Hammack, M.D., Veterans Administration Hospital, Birmingham, Alabama. J.A.M.A.
165:24-27, 1957.

JANUARY 1958

15

Care of the Patient with a Colostomy

WILLIAM C. BERNSTEIN, M.D.

St. Paul, Minnesota

There is much misunderstanding and mis-
information relative to the status of the pa-
tient with a colostomy, and I hesitate to admit
that much of this misinformation originates with
physicians. Far too many doctors feel that a
colostomy is a dreadful contraption that must
not be considered for a patient except as a last
resort. The truth of the matter is that a well-
functioning colostomy is a wonderful device that
makes it possible for people with serious illnesses
and malignant tumors to be restored to health.
These people can live relatively normal lives and
can be economically independent and socially
acceptable. Experience in caring for a large
number of patients for many years has convinced
me that an intelligent and cooperative patient
does not feel that his colostomy is much of a
handicap. However, we cannot expect all pa-
tients to be intelligent and cooperative, but we
should expect every doctor who assumes respons-
ibility for the care of patients who need this type
of surgery to equip himself with the necessary
information on the subject. Unfortunately for
the patients, too few physicians have shown
enough interest in colostomy problems in the
past. A surgeon may perform an excellent bowel
resection and provide the patient with a good
anatomic colostomy, but, if that patient is not
given proper instructions regarding the care and
function of the colostomy, he soon is in trouble.
He becomes miserable until an attempt is made
to help him adjust to his new way of life. By that
time, some patients have become depressed and
quite unable to cope with the problems involved.
A planned method of approach by the physician
before surgery, during the period of hospitaliza-
tion, and during the period of convalescence
usually pays big dividends in helping the patient
adjust to his new situation and to become reha-
bilitated in his family and outside environments.

When a patient learns that he has a veiy ser-
ious illness which often is due to a cancerous
tumor, the blow is hard to take, Add to this
trauma the knowledge that a colostomy must be

WILLIAM C. BERNSTEIN US' clinica 1 USSOCWte pwfeSSOr

of proctology in the Department of S urgert/ at the
University of Minnesota.

performed and that he will have to accept a com-
plete change in his bowel elimination and the
shock is often overpowering. At times, the effect
on the patient is so serious that he may refuse
surgery altogether. In other cases, the patient
may become depressed and feel that his future
will be dark and dismal. It is at this point that
an understanding and well-informed physician
can do a tremendous amount of good. The
choice of words used in describing a colostomy
is very important. A colostomy should never be
referred to as “an opening in the side.” This ex-
pression came into use about 1800 when the first
lumbar colostomy was performed by Callisen1
in Copenhagen. To my knowledge, no one has
performed a “side” colostomy since the 1890’s.
A few minutes devoted to an explanation of
how a colostomy works and how it can be regu-
lated, augmented by a few well-chosen case
histories of persons who are completely rehabili-
tated, does much to restore the patient’s equilib-
rium and implant a feeling of hope and confi-
dence. Merely to tell a patient that the rectum
must be removed and that an artificial opening
will be made on the abdomen is, to my mind,
a cruel approach and must produce frightening
thoughts in patients.

Much has been written in recent years on this
subject. Lay persons as well as physicians have
become aware of the gravity of this problem and
have taken an active part in the educational pro-
gram for physicians and patients. In some cities,
clubs have been formed to help in the rehabili-
tation of colostomy patients. These organizations
have done much to lessen the load of the physi-
cians and to improve the mental attitude of the
patients. They have also made available much
information concerning newer technics and ap-
pliances which may be of use to colostomv
patients.

Each doctor must approach this problem in
his own way. However, since the ultimate goal
is the same in each case, namely, a well-adjusted
and rehabilitated patient, certain basic principles
must be observed. I will attempt to describe
our approach in the handling of these patients,
since we feel that the end results have been uni-
formly good. When we diagnose cancer of the

16

THE JOURNAL-LANCET

rectum or any other disease requiring a perma-
nent colostomy, we explain that the surgery will
entail construction of a new opening, which will
serve very satisfactorily and with little inconven-
ience to the patient. We assume a very optimis-
tic attitude and try never to instill a feeling of
doubt or fear in the patient’s mind. We are quite
positive in our approach and, if the patient mani-
fests some real anxiety, we suggest that we will
he glad to bring in a patient who has a colostomy
and who is happy with it. We try to forewarn
the nurses on the hospital floor where the patient
is to be admitted so that they will assume an op-
timistic attitude toward the patient and his ill-
ness. A thoughtless nurse can destroy all of the
confidence the physician has built up in the
patient. We have had several bitter experiences
resulting from tactless remarks about those “aw-
ful” colostomies. Some nurses offer unsolicited
sympathy to these patients without realizing the
damage they are doing.

After surgery, these patients are prone to be
apprehensive and fearful of their new status.
We make every attempt to bolster their morale
and, on the day that the colostomv is opened, we
explain that the first few times the colostomy
functions we are unable to predict whether the
stool will be well-formed, soft, or watery. We
state that if a waterv stool should occur and soil
the bedclothes, it is not cause for alarm or fear
that this condition will continue. We ask the
nurses to be extraordinarily helpful in keeping
these patients clean in order to avoid unneces-
sary embarrassments. Usually, the first move-
ment will be well-formed or soft. With the
advance warning we have given, the patient is
happily surprised and becomes quite satisfied
with his colostomy. After several days our pa-
tients are told that it would be well to start car-
ing for the colostomy themselves, since they will
want to be independent when they go home. It
is interesting to see how well most patients ac-
cept this assignment soon after surgery. We like
to impress upon our patients the fact that they
should not expect to have others care for their
colostomy when they are at home.

I must admit that there are healthy differences
of opinion concerning the patient’s care from this
point on. Breidenbach and Secor,2 in an excel-
lent paper published in the American Journal of
Surgery in January of this year, state that a
patient should be taught to irrigate his colostomy
about the tenth day after surgery. In this pro-
gram, we do not concur. We feel that a patient
will be in a much better position to irrigate and
to appreciate the value of irrigation after he has
learned more about the functioning of and care

of the colostomy before irrigations are started.
When our patients leave the hospital, they are
given a supply of dressings and are told exactly
how to take care of the colostomy. They are
advised to take tub baths and are told that a
soft wash cloth can be used directly on the
stoma. They are given a prescription for pare-
goric in case the bowels move too often and
are given some insight into the dietary regime.
This I will discuss subsequently. The patients
are told to report to the office at the end of two
weeks. At that time, they are interrogated in
detail as to the behavior of the colostomy. Not
infrequently, we have a patient who states that
his colostomy has given him very little trouble.
The bowel moves once a day, usually on arising
in the moring or just after breakfast. These
patients need very little further instruction. Ir-
rigation would serve only to complicate the life
of the patient and is totally unnecessary. The
other patients whose bowels move several times
a day or at erratic intervals are taught a very
simple method of irrigation. An Asepto syringe,
a catheter, and lubricant are all that are needed
in the way of equipment. We demonstrate var-
ious types of irrigating appliances, but most of
our patients are well satisfied with the simple
procedure. 1 am not surprised that many doctors
state that a certain method of irrigation, and that
alone, is the proper procedure. Nor am I sur-
prised when many patients come to me with
their ideas of the proper way to irrigate a colos-
tomy. The truth of the matter is that there are
many ways of doing it, some of which work well
for one patient while results are not the same for
others. If a patient can irrigate and empty his
colon in a period of thirty to forty-five minutes
and if he can remain clean for twenty-four to
forty-eight hours, this function is being per-
formed satisfactorily. The important point is
that the surgeon who performs the operation
should supervise the education of the patient.

There are many appliances on the market for
patients who have colostomies. We do not feel
that an appliance is necessary for an intelligent
and cooperative patient. If the bowel is emptied
well, with or without irrigation, a small piece of
gauze under an elastic abdominal support should
be all that is required. When a patient wears a
bag or a plastic pouch, it is quite obvious that
he is not doing well in emptying his bowel at
stated intervals. We have a few patients who,
in spite of good colostomy care, absolutely insist
on wearing a ring and plastic cover for their own
self-assurance. We do not feel that the point is
worth arguing. We discourage use of colostomv
belts, bags, domes, and other bulky appliances.

JANUARY 1958

17

The subject of diet is extremely important for
the patient with a colostomy. It is very easy
for such a patient to become a dietary cripple.
We do everything possible to prevent this occur-
rence. Our patients are told that they will be
able to eat essentially the same foods as they ate
before surgery. We sincerely believe that there
are verv few foods which influence the function
of the large bowel. We believe that the trans-
portation of feces in the colon is influenced more
by the neuromuscular mechanism, which de-
pends on bulk and fluid, and by the emotional
status of the patient than by any other factors.
Our patients are told to eat everything, but we
explain that they may find that one or more foods
will cause some trouble. If a patient decides that
his colon is functioning improperly because of
a certain food, it is well to omit that particular
item from the diet. In our experience, most
colostomy patients have one or two foods from
which they abstain, but, for the most part, the
diet is extremely liberal and all inclusive. It is
true that some foods, such as beans, cauliflower,
and cabbage produce more gas than others. This
is just as true in patients without colostomies.
Common sense should dictate that these foods
be avoided as much as possible. Highly spiced
foods may produce an increased amount of gas.
Each patient must decide whether this is true
in his particular case. The importance of restrict-

REFERENCES

1. Dinnick, T.: Origins and evolution of colostomy. Brit. J.

Surg. 22:142-154, 1934-35.

ing the diet in patients with colostomies has been
unnecessarily overemphasized in the past. It is
high time that this practice be discontinued. The
patient with a colostomy has been penalized
enough without being unnecessarily burdened
with a restricted diet.

This discussion would not be complete without
further comments on the value of colostomy
clubs. We are all cognizant of the value of
group therapy in emotional and other psychiatric
disturbances. The colostomy club acts as a group
therapy class. Patients with common problems
get together for discussion and to learn how best
to handle their individual problems. When a
person with a new colostomy sees other people
who are entirely rehabilitated and who are lead-
ing normal lives, it cannot help but raise his
morale. In St. Paul, we have a colostomy and
ileostomy club which has performed outstanding
service in visiting patients both pre- and post-
operatively and in helping during the period of
readjustment. I heartily recommend the forma-
tion of these clubs in all medical centers in the
country. The life of a patient with a colostomy
need not be a restricted and unhappy one. With
proper education and with the help of an under-
standing physician, these patients can lead rela-
tively normal lives. One need only to attend a
meeting of a colostomy club to appreciate the
accuracy of this statement.

2. Breidenbach, L., and Secor, S. M.: Proper handling of the
colostomy patient. Am. J. Surg. 93:50-56, 1957.

After abdominal hysterectomy, early feeding decreases the need for in-
travenously administered fluids but increases nausea, vomiting, distention, and
gas pains. Onlv 0.39 liters of intravenous fluids were given on the third post-
operative day to 38 patients fed a solid, high-protein diet immediately after
total abdominal hysterectomy, whereas administration of 0.89 liters was neces-
sary in 41 patients managed in the usual manner. Nausea and vomiting oc-
curred in 18 of the women fed the special diet but in only 8 of the controls.
Moderate or severe abdominal distention was observed in 3 of the control
group and 5 of the special diet group. Onlv 10 control subjects had moderate
or severe gas pains, whereas 15 patients fed immediately after operation had
such distress. More thorough preoperative explanation of the regimen to the
subjects might have led to better results, since some opposition to early feeding
expressed bv relatives and some of the nursing staff may have dismayed the
patients.

Joseph H. Pratt, Jr., M.D., and Glenn Cantrell, M.D., Mayo Clinic and Foundation, Roches-
ter, Minnesota. S. Clin. North America 37:1091-1099, 1957.

18

THE JOURNAL-LANCET

Comparative Clinical Pharmacodynamic
Evaluation of Newer Hypotensive Drugs

RUDOLPH E. FREMONT, M.D., F.A.C.P., F.A.C.C.
Brooklyn, New York

Although the cause of hypertension cannot
be established in the great majority of
patients with this malady, they all have in com-
mon an abnormal increase of the peripheral vas-
cular resistance at the arteriolar level. This is the
only one of the factors known to influence the
level of arterial blood pressure that is consistently
abnormal. Other factors— blood volume, cardiac
output, arterial elasticity, and blood viscosity-
become abnormal but not consistently and onlv in
complicated and advanced forms of hypertension.

There is considerable controversy concerning
the importance of humoral and neurogenic fac-
tors in relation to the increased peripheral vas-
cular resistance present in hypertension. So far.
however, onlv the neurogenic factor, manifested
by an excessive increase of the sympathetic tone,
can be modified sufficiently by therapeutic means
to lead to reversibility of the hypertension or
postponement of the organic sequelae.

Until recently, chemotherapy directed against
the excess activity of the sympathetic nervous
system was greatlv handicapped by the inade-
quacy and nonspecificity of the drugs available.
The dissatisfaction with the results of medical
therapy led, therefore, to rapid and widespread
acceptance of surgical therapy when sympa-
thectomy was shown to be effective in reducing
hypertension and in abolishing secondary symp-
toms and sequelae.

When eventually large statistics of surgically
treated patients became available, their compari-
son with adequate control observations revealed,
however, to quote Page, “a few brilliant succes-
ses, some patients definitely . . . benefited and
some not at all.”

A renewed chemotherapeutic attack upon hy-
pertension has been under way since the end of
the last war due to the discovery of a number
of drugs of sufficient potency and specificity to

rudolph e. fremont is chief of the Cardiovascular
j Section at Veterans Administration Hospital , Brook-
lyn, New York and clinical assistant professor of
medicine at the State University of New York, Down
State Medical School.

affect the hypertensive state both as produced
experimentally and as encountered in man. The
ever increasing number of these drugs, their
pronounced variation in chemical structure,
pharmacodynamic activity, and potency of both
specific and nonspecific character have brought
with them a similarly high variation in clinical
applicability. This often confusing and poten-
tially hazardous situation requires a critical ap-
praisal at frequent intervals. This is the reason
for the following review, which attempts a com-
parative clinical pharmacodynamic evaluation of
the most important antihypertensive drugs.

DEFINITION AND CLASSIFICATION

Hypotensive agents can be classified in a general
manner into those that influence the peripheral
resistance bv: (1) direct inhibition of the vaso-
motor center, ( 2 ) blocking of autonomic ganglia,
and (3) adrenergic blocking at peripheral sym-
pathetic nerve endings. Such classification is
however, misleading unless it is understood to
reflect merely the predominant action of a par-
ticular hypotensive agent. Many act simultane-
ously at different sites within the sympathetic
nervous system ( table 1 ) . Another matter of
terminology and inherent implication of action
deserves discussion. Much has been made until
verv recently of the differentiation between the
“sympatholytic” and the “adrenolytic” effects of
some of these hypotensive agents. The first sup-
posedly indicates a blocking of sympathetic nerve
activity, the last a blocking or neutralization of
circulating adrenergic substances, such as epi-
nephrine and norepinephrine. It has been dem-
onstrated conclusively that such differentiation
is artificial and that it merely reflects the predom-
inating activity of a hypotensive drug which, al-
most without exception, can be shown to have
complex activity. In general, the sympatholytic
action is less marked than the adrenolytic.

The broader term “adrenergic blockade” was,
therefore, recommended by Nickerson for the
description of the activity of these agents, and
it has found general acceptance. It is, however,
often used to describe the action of hypotensive

JANUARY 1958

19

TABLE 1

SITE AND DEGREE OF EFFECT OF HYPOTENSIVE AGENTS

Drug

Ganglionic

“ Sympatholytic ”

“Adrenolytic”

CNS

Humoral

Other

1 . Dibenamine

0

+

+ +

+ +

0

2. Piperoxan

0

0

+ +

+

0

3. DHE alkaloids

0

+ +

+

+

0

4a. Priscoline

0

+ +

+

+

0

b. Regitine

0

+

+ ( + )

( + )

0

5. Hydralazine

0

++

+

+

+

6a. TEA

+

b. C5

+ +

0

0

0

0

C. Co

+ + +

7. Thiophanium derivative

( + )

+

+

+

0

8. Veratrum alkaloids

0

0

0

p

0

Card?

9. Rauwolfia

0

0

0

+

0

drugs that decrease peripheral resistance bv
mechanisms other than adrenergic blockade.
Obviously, such terminology is again misleading
and should be abandoned in favor of the general
term of “hypotensive action.”

SITE OF EFFECT AND CHEMICAL STRUCTURE

Table 1 demonstrates the site of action of the
hypotensive drugs to be presently discussed.
Their degree of activity is characterized by the
use of symbols. A consideration of the chemical
structure and its relation to the pharmacologic
activity reveals striking differences both in chem-
ical structure and pharmacodynamic activity of
the drugs under consideration.

Dibenamine, one of the most potent and most
highly specific adrenergic blocking agents, is a
/3-haloalkvlamine related to the nitrogen mus-
tards. Related to it are its benzyl-methyl phe-
noxyethyl derivative ( Dibenzyline ) and piper-
oxan (Benodaine). The adrenergic blocking ac-
tivity of these drugs depends on the basic chemi-
cal structure /3-phenylethylamine (figure 1) which
they have in common. The specific adrenergic
blocking activity of these and related tertiary
amines presupposes a particular chemical reac-
tivity with the formation of highly active inter-
mediate compounds.

The next group of agents showing adrenergic
blocking action is made up of structurally com-
plex substances. They are obtained bv hydro-
genation of the three alkaloids contained in ergo-
toxine: namely, ergocornine, ergocristine and
ergokrvptine. This process of reduction increases
the adrenergic blocking effect of these alkaloids

and decreases at the same time their ability to
stimulate smooth muscle. These three alkaloids,
referred to subsequently as DHE alkaloids, have
in common a dimethylpyruvic acid, an amino
group, and proline as the protein molecule. Their
difference in adrenergic blocking activity appears
to be related to the difference in the type of
amino acid present in their structure.

However, this group, available for clinical use
under the name of Hydergine, does not exhibit
as exclusively an adrenergic blocking activity as
Dibenamine, since it shows also direct central
effect. This additional action was overlooked for
some time but is now well recognized as being
responsible to a considerable degree for the so-
called sympatholytic effect. The duration of ac-
tivity of these agents is moderate.

Another group of chemically related hypoten-
sive agents, consisting of Priscoline and Regitine,
exhibits mixed adrenergic blocking and central
activity. The chemical structure is basically that
of imidazoline and as such is related to histamine
(figure 2). This relationship is considered a
possible explanation for the many histamine-like
effects of Priscoline and Regitine.

There is some controversy as to whether Prisco-
line is more strongly sympatholytic or adrenoly-
tic. Species differences may account for the dis-
crepant data obtained in animal experiments. In
man, the direct depression of sympathetic nerve
activity appears more pronounced than the ad-
renolytic effect. In addition, a direct central in-
fluence is also often evident. The duration of
activity of Priscoline is quite short, though slight-
ly longer than that of piperoxan. Regitine dis-

20

THE JOURNAL-LANCET

plays a more pronounced adrenolytic action than
Priscoline and one of longer duration than piper-
oxan.

The next hypotensive agent of importance is
hydralazine, an abbreviation for 1-hydrazinoph-
thalozine, available clinically under the name of
Apresoline (figure 3). This drug shows mixed
activity with only very slight adrenolytic and
moderate sympatholytic activity. The main site
of its effect lies centrally, probably at the hypo-

H

N— ch

HC

HISTAMINE

N— CH-CH2-CH2-NH2

H,C

CH2— C

H

N-CHZ

n-ch2

N— C

H

, N — C H2

N — C H2

PRISCOLINE

REGITINE

Fig. 2. Chemical relationship of Priscoline and Regitine
to histamine.

0 - PHENYLETHYLAMINE
RADICAL

0 1 BEN AM I N E

Fig. 1. Chemical struc-
ture of Dibenamine, Di-
benzvline, and piperoxan
shown to be basically the
same as /3-phenvlethyla-
mine.

DIBENZYL I NE

PIPEROXAN
(933 F)

thalamic level. It appears further to be the onlv
hypotensive agent available which, according to
early and as yet inadequately confirmed reports,
blocks pherentasin, a humoral vasopressor sub-
stance demonstrated in cerebral extracts.

We come next to the ganglionic blocking group
of quaternary ammonium compounds, tetractlujl-
ammonium (TEA), pentamethonium (C5) and
hexamethonium (C6). Chemically, all three show
a striking relation to acetylcholine (figure 4).

It is suggested that the pharmacologic effect
of these agents which block both sympathetic
and parasympathetic activity at the ganglionic
level is due to interference with acetylcholine
activity. They are highly potent hypotensive
drugs, with potency weakest in TEA and most
marked in C6. Newer related compounds such
as pendiomid and pentolinium ( pentapyrrolidin-
ium) have been introduced recently into clinical
usage. The most promising is pentolinium tar-
trate marketed as Ansolvsen. This whole group
of agents will be referred to subsequently as the
methonium group.

Of entirely different chemical constitution is
Arfonad, a Thiophanium derivative. Pharmaco-
dynamically, it resembles TEA with its gangli-
onic blocking effect but differs from it by the
additional possession of moderate adrenergic-
blocking and central activity.

The next important group of hypotensive

JANUARY 1958

21

NH— NH2- HCL

Fig. 3. Chem-
ical structure of
hydralazine.

HYDRALAZINE

agents is derived from Veratrum viride. Several
alkaloids have been extracted, some in fairly
purified form. These alkaloids and even their
crystalline fractions are very complex com-
pounds. Chemically, some of them are esters,
others alkamines. The latter have been foun 1
to have sterol structures. Veriloid and protover-
atrines A and B, the latter under the name of
Veralba, are the two most extensively studied
fractions and have come into general clinical use.

Although Veratrum is an almost ancient drug,
the mechanism of its hypotensive action has been
elucidated only very recently. Because of the
bradycardia appearing in association with the
hypotension and because of the lack of any
demonstrable effect upon any part of the intact
sympathetic nervous system, it was thought for
a long time that the hypotensive activity of Vera-
trum alkaloids was in some manner tied up with
the Bezold reflex, whose afferent fibers arise in
the myocardium of the left ventricle. However,
cross circulation experiments in dogs in whom
head and body circulation were completely sep-
arated except for intact nervous communication
have shown that hypotension in the body can be
obtained when Veriloid or Protoveratrine is in-
jected into the head circulation alone and is then
not accompanied by bradycardia. Since in man
these agents similarly cause hypotension without
significant bradycardia, it seems reasonable to
assume a central (hypothalamic) site of action
in man. More recently, experimental work has
yielded data suggesting that the hypotensive
effect may be mediated via the carotid sinus.

Another hypotensive agent has recently been
introduced into clinical use and has become
established quickly as one of the most widely
applicable drugs for the treatment of hyperten-
sion. It is a mixture of alkaloids extracted from
the Indian plant Rauwolfia serpentina. They

have been broken down into several purified
fractions, of which reserpine was found to be one
of the most active. The site of action of this agent
appears to be limited to the hypothalamic region.
It does not block ganglia nor is it adrenolytic or
sympatholytic. The basic chemical structure of
reserpine alkaloids as well as many of the phar-
macodynamic effects resemble those of yohim-
bine, an ancient “sympatholytic” drug.

PHARMACODYNAMIC MANIFESTATIONS OF
HYPOTENSIVE ACTIVITY IN MAN

When pharmacologic and pharmacodynamic data
obtained with hypotensive agents in animal ex-
periments are applied to man, considerable diffi-
culties may be encountered. Most important are
those related to species differences. These are a
familiar phenomenon to the experimental phar-
macologist but tend to escape the attention of
the clinician who is too eager to translate phar-
macologic findings into clinical usage. These
considerations must prevail as long as basic ex-
perimental work in animals is required for the
study of drugs. In the instance of hypotensive
agents, this means the use of common carotid
occlusion, central vagal stimulation, stimulation
of the superior cervical ganglion of the cat, and
the nictitating membrane. However, certain pro-
cedures, such as cold exposure, the Valsalva ma-
neuver, tiltback and orthostatic maneuvers, and
the digital inspiratory constrictor response, allow
even in the moderately ill patient the observation
of vasopressor stimulation and the antagonism
by hypotensive drugs. Even the blocking effects
upon the action of adrenergic drugs, such as
epinephrine and norepinephrine, and of the cho-
linergic substances can be studied in man with
safety. Furthermore, newer methods of renal
clearance, cardiac and coronary sinus catheteri-
zation, and cerebral blood flow studies permit
the observation of the effect of hypotensive drugs
on the most vital compartments of the circula-
tion in man.

Thus, while data obtained with these methods
are not able to pinpoint all of the effects of hypo-
tensive agents in man, considerable information
is gained regarding the nature of the desired
specific action and any undesirable side effects
of these drugs.

There are, however, some fallacies inherent in

C2 h5

C2 H5

N— CL

CH3 / ch3

CH3 — ^N-(CH2)6-N^— CH3

ch3 ch3

Fig. 4. Chemical relation-
ship of TEA and hexa-
methoniuni to acetylcholine.

ACETYLCHOLINE TEA(ETAMON) C6 (HEXAMETHONIUM)

22

THE JOURNAL-LANCET

TABLE 2

COMPARATIVE VASOMOTOR RESPONSE TO HYPOTENSIVE AGENTS

Drug

Rate

Blood

Nor-

mals

pressure of
Hyper-
tensives

Orthostatic

hypotension

Cold Valsalva Tilthack

pressure overshoot overshoot

At

BP

tercn-l

PR

Epinephrine
BP PR

1. Dihenamine

A

zb

y

+ + +

TOTAL BLOCK

y

0

y

0

2. Piperoxan

A

zb

OA

0

0

y

A

y

zb

3. DHE alkaloids

V

oy

y

+

PARTIAL BLOCK

0

0

0

o

4. Priscolinc

A

zb

A

+

PARTIAL BLOCK

0

0

0

0

5. Hydralazine

A

y

y

+(+)

NEAR TOTAL BLOCK

y

A

y

0

6a. TEA

y

+

b. C5

A

y

y

+(+)

PARTIAL BLOCK

A

0

A

0

c. Cfi

y

+ +

7. Thiophanium

A

y

y

+(+)

Block

y

0

y

0

derivative

8. Veratrum

y

zb

+(+)

0 0 0

y

0

y

0

alkaloids

9. Rauwolfia

y

zb

y

0

0 0 0

0

-

0

-

testing the efficacy of these drugs in man. These
must be kept in mind when pharmacodynamic
data are used as a basis for therapeutic applica-
tion. First, the response of a given patient to a
drug administered intravenously in the course of
an acute experiment is not necessarily the same
as during a period of prolonged maintenance.
Developing tolerance on one side and cumula-
tive action and inherent side effects on the other
side may cause decisive differences that can
negate all predictability of a therapeutic res-
ponse based on preliminary testing. Second, even
in the acute experiment, the observed results of
vasomotor and general hemodynamic responses
to drugs that affect the sympathetic nervous sys-
tem are notoriously variable. This may be due in
any given instance to the degree of initial sym-
pathetic constrictor tone, the degree of organic
vascular disease present, the extent of blockade
achieved, and the resultant blood pressure re-
duction. It is with these limitations in mind that
we present in the following tables a survey of
the comparative vasomotor response to these hy-
potensive agents (table 2), their effect on renal
dynamics (table 3), and their over-all effect on
the circulation through various vascular compart-
ments ( table 4 ) .

It appears superfluous to elaborate on all the
data assembled and presented in these tables.
Most of them are self-explanatory. However,
those germane to a discussion of criteria for the
most desirable hypotensive drug deserve emphasis.

CRITERIA FOR DRUG SELECTION

The criteria to be fulfilled by the ideal hypoten-
sive drug may be listed as follows:

1. High specificity.

2. Blocking of strong vasopressor stimuli.

3. Significant reduction of blood pressure.

4. Favorable effect upon symptoms and signs
of hypertension.

5. No undue increase of pulse rate.

6. No impairment of circulation through kid-
ney, brain, and coronary arteries.

7. Easy, preferably oral, administration.

8. High therapeutic index.

In regard to specificity, if, under this term,
exclusive influence upon the sympathetic nervous
system with resultant reduction of the blood
pressure is understood, then no drug presently
available can be said to possess this character-

TABLE 3

COMPARATIVE EFFECT OF HYPOTENSIVE AGENTS ON
RENAL FUNCTION

Drug

Glomerular Renal

filtration blood flow

Filtration

factor

Urine

volume

1. Dihenamine

initiaiy initial

y

variable

-

2. DHE alkaloids

initiaiy initial

y

0

y

3a. Priscolinc
b. Regitine

y

y

4. Hydralazine

yy

A

y

A

5a. TEA

b. C5

c. Cfi

y

oy

variable

y

6. Thiophanium
derivative

y

y

—

y

7. Veratrum
alkaloids

y

y

—

y

8. Rauwolfia

zbD

zb

zb

-

D lor dog

JANUARY 1958

23

TABLE 4

COMPARATIVE OVER-ALL EFFECT OF HYPOTENSIVE AGENTS

ON

CIRCULATION THROUGH

VARIOUS VASCULAR

AREAS

Drug

Peripheral

Coronary

Renal

Cerebral

Splanchnic

1. Dibenamine

A

0

A

A

NH

2. DHE alkaloids

A

A

A

aa

A

3. Priscoline

A

A

D

OA

A

A

-

4. Hydralazine

A

A

A

—

5a. TEA

A

OA

NH

b. C5

A

OA

OA

AO

A

c. Ce

A

A

6. Thiophanium

A

—

A

±N

_

derivative

7. Veratrum

0

0

A

A

alkaloids

8. Rauwolfia

-

0

0

-

-

D for dog

N for normotensive man
H for hypertensive man

istic, with the possible exception of the Veratrum
and Ranwolfia groups.

The blocking of strong vasopressor stimuli and
significant reduction of the blood pressure are
interrelated. Table 2 demonstrates that those
drugs that, in a potent manner, block pressor
stimuli from which one likes to protect the over-
reacting hypertensive patient, usually cause mod-
erate to severe orthostatic hypotension. This
effect is not limited to the ganglionic blocking
agents hut holds for all drugs that show moder-
ate to marked hypotensive effects. It is so exces-
sive in the case of Dibenamine that this drug
cannot be used for the treatment of hypertension
and so pronounced in the case of the methonium
group that treatment must be administered with
utmost caution.

An attempt to select a drug that possesses the
desirable property of slowing rather than acceler-
ating the pulse rate yields only a few, the DHE,
Veratrum, and Rauwolfia alkaloids. In mean,
this effect is considerable only with the Rauwolfia
group and minimal and inconstant with the other
two. Fortunately, those hypotensive drugs in
clinical use that accelerate the heart rate do so
only rarely to an excessive degree.

Since of all circulatory compartments, the renal
circulation maintains the most intimate and in-
terdependent relationship to hypertension, there
is ample reason for careful evaluation of the
effect of hypotensive agents upon the dynamics
of the renal circulation. The ideal effect would
be one of increased renal blood flow regardless
of whether renal involvement plays a primary or
secondary role in hypertension. As evident from

table 3, only one drug, hydralazine, has been
demonstrated to possess this effect. All the other
potent hypotensive drugs tend to depress renal
function, all the more so the higher the initial
blood pressure and the more severely disturbed
the renal function is prior to treatment. This is
most pronounced in the malignant phase of hy-
pertension with uremia and least striking when
hypertension is moderate and renal function only
slightly disturbed.

Observations involving the prolonged use of
hydralazine have, however, shown that the in-
itially increased renal blood flow may eventually
return to normal levels. Similarly, the initial re-
duction of the renal blood flow produced by the
methonium group and protoveratrines tends also
to disappear with prolonged use. This may ex-
plain the occasional increase in urinarv output
and drop of blood urea nitrogen observed clini-
cally.

As regards the effect upon the other circula-
tory compartments, table 4 reveals no undue di-
rect effect of any of the hypotensive agents under
discussion upon the coronartj circulation. A few
have been shown in animals or man to be act-
ually able to increase coronary blood flow to a
slight degree. This is hardly of any clinical sig-
nificance. The effect upon the cardiac output has i
been studied in the case of several hypotensive
drugs. Some, like the DHE alkaloids and hydra-
lazine, tend to increase the cardiac output, the
first mainly by a centrally mediated increase of
the rate, the latter both by this means and poss-
ible direct stimulation of the myocardium. The
clinical significance of this is demonstrated by

24

THE JOURNAL-LANCET

the not infrequent occurrence of angina pectoris
with or without preceding tachycardia and even
of myocardial infarction in hypertensive patients
with coronary disease treated with hydralazine.

Other hypotensive drugs, such as the Veratrum
and the methonium groups, tend to decrease the
cardiac output. It is not certain whether this is
accomplished by direct depressive action upon
the myocardium, as has been held for a long
time in the case of Veratrum, or via splanchnic
pooling and resultant decrease of venous return,
as appears more recently documented for both
the methonium and Veratrum group. This effect
has actually proved of benefit to hypertensive
patients in acute left ventricular failure.

In general, however, any precipitous drop of
the blood pressure, particularly when associated
with an increase of the pulse rate, may precipi-
tate myocardial ischemia and even infarction.
Thus, where concern for the integrity of coronary
circulation is paramount, the use of drugs, such
as hydralazine, the methonium group, and Vera-
trum alkaloids, must be particularly circumspect.
The use of reserpine in combination with such
agents should prove particularly advantageous in
these circumstances by virtue of its ability to
slow the rate and also to decrease the need for
larger doses of the more potent hypotensive
drugs.

Regarding the cerebral circulation ( table 4 ) ,

fortunately, none of the drugs under discussion
decreases cerebral flow. Many decrease cerebral
resistance in line with the drop of the systemic
blood pressure, but, again, as in the case of the
hypertensive patient with coronary disease, the
one with cerebrovascular involvement must not
be subjected to precipitous reduction of the
blood pressure, since this is bound to lead to
severe decrease of cerebral blood flow.

Limited documentation is available regarding
the effect of hypotensive drugs upon the splanch-
nic circulation. Undoubtedly, it participates with
skin and muscle circulation to a considerable
degree in the general relaxation of the peripheral
vascular resistance, which is responsible for the
reduction of the blood pressure.

As regards administration, table 5 summarizes
data based, in addition to the basic pharmacody-
namic properties, also on such factors as the
speed of onset of activity, feasible route of ad-
ministration, speed of excretion, duration of ac-
tivity, cumulative effects, and development of
tolerance. Extensive and carefully conducted
clinical studies have shown that most of the hy-
potensive drugs now available leave much to be
desired in terms of ease of administration.

The clinical applicability is further compli-
cated by a variable incidence and degree of side
effects (table 6).

The latter are not limited to systemic toxicity

TABLE 5

CRITERIA FOR DESIRABLE CHARACTERISTICS OF HYPOTENSIVE DRUGS AND RELATIVE STANDING OF THOSE NOW IN USE

Improvement

Slowing

Unimpaired blood

Easy

High

Blocking of

of symptoms

of heart

flow

administration

tlxera-

Sped-

vasomotor

Reduction

and of

rate

Coro-

Cere-

Paren-

peutic

Drug

flcity

stimuli

of BP

hypertension

Renal

nary

hral

teral

Oral

index

1. Dibenamine

No

Marked

Marked

—

No

No

Yes

—

No

No

No

2. Dibenzyl ine

No

Slight

Slight

No

Yes

Fair

n tv

No

No

No

No2

4. DHE alkaloids No

Slight

Minimal

Minimal

Occas.

No

Yes

Yes

Yes

Yes

Yes

5. Priscoline

No

Slight

Minimal

No

Yes

Yes

Yes

Yes

Yes

Yes

r n

No

No

7. Hydralazine

No

Marked

Mod.

Yes

No

Incr.

Usually

Yes

Yes

Yes

Yes

8. Methonium

group

No

Marked

Marked

Yes

No

No

Yes'

Yes'

Yes

Fair

Fair

9. Arfonad

No

Mod

Mod.

No

No

—

—

Yes

No

Fair

10. Veratrum

alkaloids

Yes?

Slight

Mod.

Yes

Occas.

No

Yes1

Yes1

No

No

No

1 1 . Reserpine

Yes?

No

Slight

Yes

Yes

Yes

Yes

Yes

Yes

Yes

Yes

1Except with precipitous drop of blood pressure.

^Associated with hypertensive crisis occasionally induced by piperoxan.

JANUARY 1958

25

TABLE 6

CLINICAL

APPLICABILITY AND

SIDE EFFECTS OF

HYPOTENSIVE AGENTS

Peripheral

Hypertensive

Pheochromo-

Side effects

Drug

vascular disease

vascular disease

cytoma

Degree

Incidence

la.

Dibenamine

+

+

+ +

Severe

Freq.

b.

Dibenzyline

+ +

+ +

0

Mod.

Freq.

2.

Piperoxan

0

0

+ + +

Mod.

Freq.

3.

DHE alkaloids

+ +

+

0

Mild

Freq.

4a.

Priscoline

+ + +

0

Mod.

Freq.

b.

Regitine

+ ( + )

0

+++

Mild

Freq.

5.

Hydralazine

( + )

++

0

Mod.

Severe

Freq.

Occas.

6a.

TEA

( + )

(+)

+

Mod.

b.

C5

+

++

—

Mod.

Freq.

c.

C«

+ ( + )

+ H — h

—

Severe

7.

Thiophanium derivative

( + )

(+)

—

0

—

8.

Veratrum alkaloids

0

++

0

Mod.

Severe

Freq.

Occas.

9.

Rauwolfia

0

+(+)

0

Minimal

Occas.

but also frequently involve excesses of the in-
herent pharmacodynamic activity. Examples of
the first type are the occurrence of a lupus
erythematosus-like syndrome produced by the
prolonged use of large doses of hydralazine
and gastrointestinal intolerance observed with
Dibenzyline and Priscoline. Examples of the
second type are the unpredictable and, at times,
unavoidable peripheral vascular collapse follow-
ing the use of Veratrum drugs; the excessive cen-
tral stimulation by Dibenamine, resulting in de-
lirium and convulsion; unpleasant tremulousness
after use of DHE alkaloids; severe depression
occasionally seen with Rauwolfia; and accom-
modation paralysis noted with the methonium
group.

These side effects do not affect the clinical
applicability of these drugs in terms of their use-
fulness in peripheral vascular disease, hyperten-
sive cardiovascular disease, and hypertension
due to pheochromocytoma (table 6). Their re-
spective place in the management of these con-
ditions depends primarily on their site and de-
gree of pharmacodynamic activity as seen in
table 1. Thus, those drugs with markedly pre-
dominant adrenolytic action are best suited for
the diagnostic and therapeutic management of
crises due to a pheochromocytoma. Those with
relatively strong, if not exclusive, sympatholytic
action are most useful as peripheral vasodilators,
while the ganglionic blockers tend to be useful
only as hypotensive agents. Their predominant
effect upon the blood pressure makes their use

for the treatment of peripheral vascular disease
impracticable and often impossible even in nor-
motensive patients. They can be employed, how-
ever, on a short term basis for the diagnostic
evaluation of peripheral vascular conditions, such
as the presence or absence of peripheral vascular
spasm.

CONCLUSIONS

Evaluation of available hypotensive drugs in the
light of the pharmacodynamic and clinical ob-
servations makes it obvious that no single hypo-
tensive agent has yet been found able to fulfill
all criteria of desirability. A careful selection of
a combination of hypotensive drugs and the fre-
quent addition of drugs counteracting their side
effects are at present the best and only working
solutions for the management of all but the mild-
est forms of hypertension. Such a selective order
of hypotensive drugs is offered in table 7.

The choice is based on the consideration of all
basic pharmacodynamic data in animal and man
and the likely clinical response of patients in
various phases of hvpertensive vascular disease.
It is recommended as a systematic approach to
the medical management of hvpertension and,
as such, has proved of great practical usefulness
in our experience. It may well be modified as
better hypotensive drugs become available.

ADDENDUM

Since completion of this review, two new hvpo-
tensive drugs have become available, Ecolid

26

THE JOURNAL-LANCET

TABLE 7

SELECTION OK HYPOTENSIVE DRUGS FOR TREATMENT OF HYPERTENSION

Hypertensive

state

Initial Drug It

1

Additional drugs in order of choice

2 3

1. Mild, symptomatic

Reserpine

Usually

not

required

2. Mod., with grade 3
fundi

Reserpinc

Apresoline

Ansolysen

Protoveratrine

3. Moil, or severe, with
a. Card, failure
or

Reserpine

Ansolysen

Protoveratrine

Apresoline

h. Coronary insuff.
c. Renal insuff.

Reserpinc

Apresoline

Protoveratrine

Ansolysen

d. Cerebrovascular
insufficiency

Reserpine

Apresoline

Ansolysen

or Protoveratrine

4. Acute hypertensive
encephalopathy

i.v. Protoveratrine

or Ansolysen

or Apresoline

or Reserpine

5. Malignant phase
a. Incipient

Reserpine

Protoveratrine Ansolysen

Apresoline

b. Established
1 . renal insuff.

Reserpine

Apresoline

Protoveratrine

Ansolysen

2. card, insuff.

Reserpine

Ansolysen

Protoveratrine

Apresoline

( chlorisondamine dimethochloride ) and meca-
mvlamine, marketed as Inversine, a secondary
amine ( 3-methylaminoisocamphane hydrochlor-
ide). Both are potent ganglionic blocking agents
and, according to experimental and limited clini-

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Proc. Soc. Exper. Biol. & Med. 67:163, 1948.

Dl HYDROERGOT ALKALOIDS

19. Hartman, M., and Isler, H.: Chemische Konstitution und

pharmakologische Wirksamkeit von in 2- Stellung substituier-
ten Imidazoline. Arch, exper. Path. u. Pharmakol. 192:141,
1939.

20. Stoll, A., and Hoffman, A.: Die Alkaloide der Ergotoxin-

gmppe: Ergocristin, Ergokrvptin und Ergocormin. Helvet.

chem. acta 26:1570, 1943.

21. Rothlin, E.: Zur Pharmakologie der hydrierten naturlichen

Mutterkomalkaloide. Helvet. med. acta 2:48, 1944.

22. Bluntschli, H. J., and Goetz, R. H.: Effect of ergot deriva-
tives on circulation in man with special reference to 2 new
hydrogenated compounds. Am. Heart J. 35:873, 1948.

23. Bancroft, H., Konzett, H., and Swan, H. J. C.: Observa-
tions on action of hydrogenated alkaloids of ergotoxine group
on circulation in man. J. Physiol. 112:273, 1951.

PRJSCOLINE

24. Grimson, K. S., Reardon, M. J., Marzoni, F. A., and Hen-
drix, J. P. : Effects of Priscoline on peripheral vascular dis-

eases, hypertension and circulation in patients. Ann. Surg.
127:968, 1948.

25. Ahlquist, R. P., Huggins, R. A., and Woodbury, R. A.:
Pharmacology of benzylimidazoline (Priscol). J. Pharmacol.
& Exper. Therap. 89:271, 1947.

PIPEROXAN

26. Vleeschhouwer, G. R. de: Au sujet de Faction du diethyl-

JANUARY 1958

27

aminomethvl-3-benzodioxane ( F 883 ) et du piperido-methyl-
3-benzodioxane ( F 933 ) sur le systeme circulatoire. Arch,
internat. pharmacodyn. 50:251, 1935.

27. Bovet, D., and Simon, A.: Recherches sur l’activite sympa-
tholytique des derives de l’aminomethylbenzodioxane. Arch,
internat. pharmacodyn. 55:15, 1937.

28. Goldenberg, M., Snyder, C. H., and Aranow, H., Jr.: New
test for hypertension due to circulating epinephrine. J.A.M.A.
135:971, '1947.

REGITLNE

29. Grimson, K. S., Longino, F. H., Kernodle, C. E., and
O’Rear, H. B.: Treatment of patient with pheochromocytoma;
use of adrenolytic drug before and during operation. J.A.M.A.
140:1273, 1949.

30. Emlet, J. R., Grimson, K. S., Bell, D. M., and Orgain,

E. S.: Use of piperoxan and Regitine as routine tests in pa-

tients with hypertension. J.A.M.A. 146:1383, 1951.

hydralazine

31. Reubi, F.: Influence de quelques vasodilatateurs peripheriques
sur le flux sanguin renal. Helvet. med. acta 16:297, 1949.

32. Schroeder, 11. A.: Effect of 1-hvdrazinophthalozine in hyper-
tension. Circulation 5:28, 1949.

33. Gross, F., Druey, J., and Meier, R.: Eine neue Gruppe

Blutdrucksenkender Substanzen von besonderem Wirkungs-
charakter. Experientia, 6:19, 1950.

34. Freis, E. D., and Finnerty, F. A., Jr.: Suppression of vaso-
motor reflexes in man following 1-hydrazinophthalozine (C-
5968). Proc. Soc. Exper. Biol. & Med. 75:23, 1950.

35. Grimson, K. S., Cittum, J. R., and Metcalf, B. H.: Action
of 1-hydrazinophthalozine (C-5968) on vasomotor reflexes
and hypertension in dog and man. Federation Proc. 9:279,
1950. '

36. Taylor, R. D., Page, I. H., and Corcoran, A. C.: Hor-

monal neurogenic vasopressor mechanism. Arch. Int. Med.
88:1, 1951.

37. Taylor, R. D., Dustan, H. P., Corcoran, A. C., and Page,

I. H.: Evaluation of 1-hydrazinophthalozine ( “Apresoline” )

in treatment of hypertensive disease. Arch. Int. Med. 90:
734, 1952.

38. Moyer, J. H., Huggins, R. A., and Handley, C. A.: Fur-

ther cardiovascular and renal hemodynamic studies following
the administration of hydralazine and effect of ganglionic
blockade with hexamethonium on these responses. J. Phar-
macol. & Exper. Therap. 109:175, 1953.

39. Perry, H. M., Jr., and Schroeder, H. A.: Syndrome simu-
lating collagen disease caused by hydralazine (Apresoline).

J. A.M.A. 154:670, 1954.

METHONIUM GROUP

40. Lyons, R. H., and others: Effects of blockade of autonomic

ganglia in man with tetraethylammonium; preliminary obser-
vations on its clinical application. Am. J. Med. Sc. 213:315,
1947.

41. Moe, G. K., and others: Evaluation of vasomotor tone in ani-
mal and man bv means of tetraethylammonium. J. Lab. &
Clin. Med. 32:311, 1947.

42. Arnold, P., Goetz, R. H., and Rosenheim, M. L.: Effect of
pentamethonium on peripheral circulation. Lancet 2:408,
1949.

43. Burt, C. C., and Graham, A. J. P.: Pentamethonium and

hexamethonium iodide in investigation of peripheral vascular
disease and hypertension. Brit. M. J. 1:455, 1950.

44. Moe, G. K., and Freyburger, W. A.: Ganglionic blocking

agents. Pharmacol. Rev. 2:61, 1950.

45. Finnerty, F. A., Jr., and Freis, C. D.: Experimental and

clinical evaluation in man of hexamethonium (C6), a new
ganglionic agent. Circulation 2:828, 1950.

46. Smirk, F. H., and Alstad, K. S.: Treatment of arterial hy-
pertension by penta- and hexamethonium salts. Brit. Med. J.
1:1217, 1951.

47. Paton, W. D. M., and Zaimis, E. J.: Methonium compounds.
Pharmacol. Rev. 4:219, 1952.

48. Moyer, J. H., Huggins, R. A., Handley, C. A., and Mills,

L. C.: Effects of hexamethonium chloride on cardiovascular

and renal hemodynamics and on electrolyte excretion. J.
Pharmacol. & Exper. Therap. 106:157, 1952.

49. Rein, H. J., and Meier, R.: Phannakologische Untersuchun-

gen iiber Pendiomid, eine neuartige Substanz mit ganglien-
blockierender Wirkung. Schweiz, med. Wchnschr. 81:446,
1951.

50. Smirk. F. H.: Action of a new methonium compound in ar-
terial hypertension. Lancet 1:457, 1953.

51. Wien, R., and Mason, D. F. J.: Pharmacology of M&B

2050. Lancet 1:454, 1953.

52. Freis, E. D., Partenope, E. A., and Rose, J. C.: Penta-

pyrrolidinium (M&B 2050) in treatment of severe hyperten-
sion. Circulation 8:448, 1953.

53. Crumpton, C. W., Rowe, E. G., O’Brien, E., and Murphy,
O. R., Jr.: Effect of hexamethonium bromide upon coronary
flow, cardiac work and cardiac efficiency in nonnotensive and
renal hypertensive dogs. Circ. Res. 2:79, 1954.

54. Com insky , B., Prudy, J. R. K., Wheeler, H. O., Hays, R.
M., and Bradley, S. E.: “Splanchnic pooling’’ during hypo-
tensive action of hexamethonium bromide in dog. J. Clin.
Investigation 33:924, 1954.

55. Freis, E. D., Partenope, E. A., Lilienfeld, L. S., and

Rose, J. C.: Clinical appraisal of pentapyrrolidinium (M&

B 2050 ) in hypertensive patients. Circulation 9:540, 1954.

56. Maxwell, R. D. H., and Campbell, A. J. M.: New sym-

pathicolytic agents. Lancet 1:455, 1953.

57. Agrest, A., and Hoobler, S. W.: Long-term management

of hypertension with pentolinium tartrate (Ansolysen).
J.A.M.A. 157:999, 1955.

58. Smith, J. R., Agrest, A., and Hoobler, S. W.: Effect of

acute and chronic administration of pentolinium tartrate on
the blood pressure and cardiac output in hypertensive pa-
tients. Circulation 12:777, 1955.

ARFONAD

59. Sarnoff, S. J., Goodale, W. T., and Sarnoff, L. C.:
Graded reduction of arterial pressure in man by means of a
thiophanium derivative ( Ro 2-2222 ) ; preliminary observa-
tions of its effect in acute pulmonary edema. Circulation 6:
63, 1952.

VERATRUM ALKALOID

60. Krayer, O., and Acheson, G. H.: Pharmacology of veratrum
alkaloids. Physiol. Rev. 26:383, 1946.

61. Meilman, E., and Krayer, O.: Clinical studies on veratrum
alkaloids; action of protoveratrine and veratridine in hyper-
tension. Circulation 204, 1950.

62. Swiss, E. D., and Maison, G. L.: Site of cardiovascular ac-
tion of veratrum derivatives. J. Pharmacol. & Exper. Therap.
105:87, 1952.

63. Currens, J. H., Meyers, G. S., and White, P. D.: Use of

protoveratrine in treatment of hypertensive vascular disease.
Am. Heart J. 46:576, 1953.

RAUWOLFIA

64. Chopra, R. N., Gupta, J. C., and Mikherjee, B.: Pharma-
cological action of an alkaloid obtained from Rauwolfia serpen-
tina. Benth: preliminary note. Indian J. M. Research 21:261,
1933.

65. Wilkins, R. W.: New drug therapies in arterial hyperten-

sion. Ann. Int. Med. 37, 1144, 1952.

66. Wilkins, R. W., and Judson, W. E.: Lise of Rauwolfia ser-
pentina in hypertensive patients. New England J. Med. 248:
48, 1953.

67. Hughes, W. M., Moyer, J. H., and Daeschner, C. W.:
Parenteral reserpine in treatment of hypertensive emergencies.
Arch. Int. Med. 95:563, 1955.

ECOLID

68. Plummer, A. J., Trapold, J. H., Earl, A. E., and Max-
well, R. A.: Ganglionic blockade in a new bisquatemary

series including Ecolid ( chlorisondamine dimethochloride
(SU 3088). J. Pharmacol. & Exper. Therap. (cited bv
Grimson, K. S. J.A.M.A. 158:359, 1955.

69. Smirk, F. H., and Hamilton, M.: Action of Ecolid in man.
Brit. M. J. 1:319, 1956.

MEC AMYL AMINE

70. Moyer, J. H., and others: Drug therapy of hypertension; pre-
liminary observations on clinical use of mecamylamine, a
ganglionic block agent. Med. Rec. & Ann. 49:390, 1955.

71. Moyer, J. H., and others: Drug therapy (mecamylamine) of
hypertension; results with mecamylamine, completely absorbed
ganglionic blocking agent. Arch. Int. Med. 98:187, 1956.

28

THE JOURNAL-LANCET

Section on PAIN

Comments concerning this Section, criticisms, or suggestions for papers will he most
welcome. Physicians are cordially invited to submit articles pertaining to pain for
consideration. All inquiries and manuscripts should be sent to Dr. John S. Lundy,
102 Second Avenue Southwest, Rochester, Minnesota, or to the Editorial Depart-
ment, The Journal-Lancet, 84 South Tenth Street, Minneapolis, Minnesota.

Management of Tic Douloureux

O

CHARLES M. POSER, M.D.

Kansas City, Kansas

Pitfalls beset the path of the medical practi-
tioner in attempting to solve the problem of
facial pain. One of the reasons is that the area
which is usually affected is served by a number
of different nerves. Among them are the trigem-
inal, some of the upper cervical roots, the glos-
sopharyngeal, the great occipital, and, possibly,
some ill-understood contributions from the sym-
pathetic pathways.

With the great number of neuroanatomic struc-
tures possibly causing pain, go an even wider
variety of etiologic agents. In 1940, Glaser1 sug-
gested the following classification of the dis-
orders comprising what he called “atypical facial
neuralgia”:

1. Primary atypical facial neuralgia of un-
known etiology.

2. Facial neuralgia secondary to such causes
as herpes, abnormalities of the mandibular joints,
convulsive disorders, nuchal myositis, and so on.

3. Atypical facial neuralgia produced by
systemic diseases, such as allergy or psychoneu-
rosis.

4. Atypical facial neuralgia secondary to in-
fection or neoplasms in the region of the head
and neck.

Unfortunately, many patients who have gen-
uine atypical facial pain go from doctor to doc-
tor forever undiagnosed and overtreated. Re-

charles m. poser is assistant professor of experi-
mental neurology at the University of Kansas School
of Medicine, Kansas City, Kansas.

Read, in part, at a Symposium on Pain under di-
rection of the Department of Postgraduate Medical
Education, University of Kansas Medical Center, and
the University of Kansas City School of Dentistry,
March 6, 1957.

cause ignorance of the pathophysiologic mech-
anism of many painful syndromes still prevails,
their real distress is labeled a “psychosomatic
reaction.”

Nevertheless, among the host of painful con-
ditions affecting the face and its surrounding
structures, one syndrome is easily differentiated.
It is called “tic douloureux” or “trigeminal neu-
ralgia" and is manifested in the areas served by
the trigeminal nerve. The description of the tics
is so characteristic that the disease may be diag-
nosed by this means alone. The presence of the
tics coupled with a completely negative neuro-
logic examination is incontrovertible evidence
for true trigeminal neuralgia.

The distinguishing features of tic douloureux
are recurrent paroxysms of sharp, stabbing, and,
occasionally, burning or searing pain in the dis-
tribution of one or more of the sensory branches
of the trigeminal nerve. The single most out-
standing peculiarity of this disease, which makes
it easy to differentiate from other painful facial
conditions, is the paroxysmal nature of the at-
tacks. They are characterized by a lightning-
like suddenness of onset, short duration (from a
few seconds to a few minutes), rapid disappear-
ance of the pain, and completely pain-free inter-
vals between attacks. When the pain is in the
ascendant, it is excruciating and almost unbear-
able. In the colorful words of Harry Lee Parker,2
the sufferer from tic douloureux “looks miserable
and haggard, and he has every reason to be so,
for he has such a pain in his face that all the
devils out of Hell might be tearing at it.”

Trigeminal neuralgia is a disease of unknown
etiology, undetermined pathology, and unex-
plained phvsiology. It occurs most commonly in

JANUARY 1958

29

Section on PAIN

middle or late life and is slightly more common
in women. Usually, it is unilateral, but in 2 to
5 per cent of the cases, there is bilateral involve-
ment.3 The second division of the trigeminal
nerve is the most commonly involved; the first,
the least often affected.

Because the pain is so severe, tearing of the
eyes frequently accompanies it. The paroxysms
of pain may occur every few minutes or the
patient mav go for days, weeks, or months com-
pletely pain free. The pain may prevent him
from holding any job and even keep him from
carrying out any of his normal daily activities.
This is particularly true if so-called “trigger
points” or “trigger zones" are present. These
are areas of hypersensitivity, which, when touch-
ed or affected by motion, set off painful parox-
ysms. They are usually located on the face or
inside the mouth. When they are part of the
syndrome, it may be difficult or even impossible
for the patient to wash, shave, speak, or eat.
The face assumes a “masklike expression of . . .
immobility. There is in this expression the hope
of avoidance and the dread of recurrence.

Avicenna was the first to differentiate this dis-
ease about 1000 A. D., but the first clear deline-
ation of the syndrome is ascribed to Fehr and
Schmidt in the latter part of the seventeenth cen-
tury.4 Fothergill ' wrote a description of it in 1773
which remains unequalled to this day.

At times, tic douloureux affecting the third
division of the trigeminal nerve is difficult to
distinguish from glossopharyngeal neuralgia. This
disease is probably identical in nature with tri-
geminal neuralgia but affects the throat rather
than the face.3 Trigeminal neuralgia may occur
in combination with glossopharyngeal neuralgia3
as well as in combination with a tic-like neuralgia
of the great occipital nerve.6

The nathology of tic douloureux has never
been elicited, although theories abound. Its on-
set in late middle life seems to offer evidence
in favor of the theory that vasospastic ischemia
of the gasserian ganglion accounts for the symp-
toms in at least some cases. Since the disease
is never fatal and surgical removal of the gasser-
ian ganglion is not performed, histopathologic
studies are scarce. In the few that have been
done, no histologic changes have been shown
that would account for the disease.

A few conditions may mimic the syndrome and
must be distinguished from it. Most important
among these are acoustic neurinomas, which
occasionally produce tic douloureux. A history
of hearing loss, tinnitus, and findings of the neu-

rologic examination should help establish the
correct diagnosis and lead to the proper therapy.
Neurinomas of the gasserian ganglion will also,
on occasion, produce similar symptomatology,
but the finding of objective sensory changes in
the division of the trigeminal nerve should im-
mediately suggest such a diagnosis.

Harris7 has pointed out that on rare occasions,
sharp shooting pains in the face may occur
following thrombosis of the posterior inferior
cerebellar artery or of small perforating pontine
branches of the basilar artery. Here again, the
presence of objective neurologic signs should
establish the fact that the disease is not true tic
douloureux.

The pain of dental or periodontal disease is
rarely confused with trigeminal neuralgia of the
second or third division of the trigeminal nerve,
while migraine equivalents seldom are limited
to the anatomic distribution of the trigeminal
nerve. The pain of Costen’s syndrome is so clear-
ly related to movements of the jaw as to be un-
mistakable. Postherpetic trigeminal neuralgia is
easily diagnosed on the basis of previous herpetic
infection, and, although it is associated with
some paroxysmal pain, there is an almost con-
stant “background” of pain. A syndrome identi-
cal to tic douloureux occurs in multiple sclerosis,
but rarely is it the first symptom of the disease.
Therefore, here too the history, age of onset, and
the neurologic findings should help in establish-
ing the etiology of the manifestation.

From the preceding, it can be seen that in tic
douloureux, the neurologic examination is always
normal, and there are never objective signs in
the sensory distribution of the trigeminal nerve.
Should such signs be present, the diagnosis of
true trigeminal neuralgia can no longer be enter-
tained.

One of the few mitigating factors in this dis-
ease is that long-term and, occasionally, per-
manent remissions do occur. This, of course,
complicates the evaluation of any medical ther-
apy. Occasionally, if the history suggests that
an episode in the disease usually lasts a few days
or, perhaps, two or three weeks and then goes
into remission for a considerable period, it is
better to withhold therapy of any kind, provided
the patient understands his illness and agrees
with this decision.

The type of therapy to be employed must de-
pend on bow severely the patient is incapacitat-
ed, not only physically by the pain but also
psychologically by his dread of the next parox-
ysm. The physician may try purely medical

30

THE JOURNAL-LANCET

Section on PAIN

therapy if attacks are infrequent or simply inter-
fere with household duties, whereas, if the pa-
tient’s employment is in jeopardy, he may find
injection or early operation necessary. The pa-
tient’s attitude toward his illness as well as the
extent, type, and success of previous therapeutic
procedures are important considerations.

Little short of injecting the offending division
can be done for the patient during the actual
paroxysm of pain. However, the paroxysm is
usually of such short duration as to make this
procedure of questionable value. If possible,
narcotics should not be used, since, in a disease
such as this, with frequent recurrences and in
which the fear of the recurrent attack is so prom-
inent, the risks of iatrogenic addiction are serious.
The inhalation of trichlorethylene every two or
three hours may give transient relief of the acute
attack.8 In attacks of moderate severity, aspirin
and codeine may be of some help.

For longer term therapy, intramuscular injec-
tions of cyanocobalamin (vitamin B^) have
relieved paroxysmal attacks in 50 to 80 per cent
of the patients.9 There are various ways of ad-
ministering this treatment, a common way being
the daily injection of 1 cc. of cyanocobalamin
containing 1,000 /.ig. per cc. for a period of ten
or twelve days. Needless to say, it is difficult to
evaluate the actual value of the therapy against
the possibility of a spontaneous remission. Evi-
dence seems to suggest that these injections may
indeed be helpful. Certainly, this simple, harm-
less method of treatment should be made avail-
able to all patients with tic douloureux.

The intravenous injection of stilbamidine ise-
thionate lias also been recommended in the treat-
ment of this condition.10 The potential toxicity of
this drug, the long period necessary before eval-
uation of results is possible, the difficulties in-
herent in continuous and repeated intravenous
therapy, and the large percentage of patients
who complain of the burning paresthesia result-
ing from the characteristic neuropathy of the
trigeminal nerve make this type of therapy of
doubtful value.

Oral administration of various vitamin prepar-
ations, including cyanocobalamin has had no
effect. Injection of the trigger zones with local
anesthetics has been ineffective in most instances.

A different form of therapy consists of the in-
jection of either local anesthetic agents, such as
procaine, or of absolute alcohol into the gasserian
. ganglion or into whichever sensory branch is
| affected. Injection of alcohol into the ganglion
was first proposed by Hartel11 in 1912. Harris12

reviewed his experience and reported extremely
satisfactory results with this method in 1,433
cases. However, the occasional resultant devast-
ating paralysis of cranial nerves has deterred
most neurosurgeons from using this method. Jae-
ger18 recently proposed injecting boiling water
into the gasserian ganglion, claiming that it was
effective in relieving tic douloureux in 98 per
cent of his patients. It has none of the dangers of
alcohol injection and is, as far as he has been
able to determine from his follow-up studies,
capable of producing complete cure.

A simpler and more popular form of therapy
has been the injection of the different sensory
branches of the trigeminal nerve at the periphery.
The first division is easily accessible at the supra-
orbital notch; the second, with some practice and
experience, can be injected through the infra-
orbital foramen; while the third division may be
injected at the mandibular foramen. If relief and
an anesthetic zone are obtained with procaine,
the needle is left in place and absolute alcohol
is then injected into the nerve. This, of course,
results in an area of anesthesia corresponding to
the area of distribution of the affected sensory
branch.

Alcohol injection remains an eminently satis-
factory means of managing tic douloureux even
though the results are rarely permanent. Peet
and Schneider14 reported that 74 per cent of their
patients obtained relief for less than two months,
and only 15 per cent were relieved for more than
one year. The alcohol injection can be perform-
ed as an office procedure and may naturally have
to be repeated on several occasions.

Because of the close association and connec-
tions with other nerves in the area, it has been
suggested that relief may be obtained by injec-
tion of other nerves. Thus, Wyburn-Mason1"’ ob-
tained relief in 56 patients with tic douloureux
by alcohol injection of the greater auricular
nerve. Crue and his co-workers Ui reported good
results by injecting alcohol into the great occipi-
tal nerve.

The value of these different tvpes of injections
must once more be viewed in relation to the
possibility of spontaneous remission in this dis-
ease. In addition, the possibility exists that al-
most any procedure might be useful as long as
the cycle of the paroxysmal attack is interrupted.
This is known to take place in the treatment of
migraine, which comes in cycles similar to those
encountered in tic douloureux. Since some
authors have postulated the establishment of
“reverberating circuits” or “self-contained eir-

JANUARY 1958

31

Section oh PAI N

cuits' in the thalamus in cases of severe pain,
such as tic douloureux, the interruption of such
a circuit by a nonspecific procedure might ex-
plain the temporary relief in the same manner as
the fact that root section may not necessarily
lead to permanent relief of the disease.

Surgical intervention is probably the best es-
tablished type of therapy for this condition. It
is almost predictable that the great majority of
patients with tic douloureux eventually require
surgery to achieve complete lasting relief.

A variety of surgical approaches to this prob-
lem were used17 until Spiller and Frazier18 intro-
duced the modern operation, which consisted of
sectioning the sensory roots between the gang-
lion and the pons. Later, this operation was
further refined by the introduction of differen-
tial root section, so that anesthesia would be
restricted only to the affected area. The results
of this type of operation are unfortunately not
entirelv satisfactory. Even though the mortality
varies between 0.5 and 1.6 per cent, postopera-
tive complications include keratitis in 5 to 15
per cent, facial paralysis in 2 to 6 per cent, and
residual paresthesia develops in approximately
half of the patients.9 The latter complication
frequently becomes the most objectionable, and
many patients complain bitterly of the constant
and painful “numbness” which has replaced the
occasional attacks of pain. In one large series,14
severe trigeminal pain recurred in 14 per cent
of patients upon whom operations were per-
formed.

A more recent procedure, introduced by Taarn-
liPj19 in 1952, consists of decompression of the
posterior root by simply opening the dural
sheath. This operation has the advantage of
not producing unpleasant postoperative pares-
thesia. Relief is obtained in a considerable num-
ber of patients. An added advantage is that post-
terior root section can always be resorted to if
the trigeminal neuralgia recurs. This operation

REFERENCES

1. Glaser, M. A.: Atypical facial neuralgia. Arch. Int. Med.
65:340, 1940.

2. Parker, H. L.: Clinical Studies in Neurology. Springfield,
Illinois: Charles C Thomas, 1956.

3. Brzustowicz, R. J.: Combined trigeminal and glossopharyn-
geal neuralgia. Neurology 5:1, 1955.

4. Lewy, F. H.: First authentic case of major trigeminal neural-
gia. Ann. M. Hist. N.S. 10:247, 1938.

5. Fothergill, J.: Cited by Crawford and Walker.17

6. Skillfrn, P. G.: Great occipital-trigeminus syndrome as re-

vealed bv induction of block. Arch. Neurol. & Psvchiat. 72:
335, 1954.

7. Harris, W.: Rare forms of paroxysmal trigeminal neuralgia
and their relation to disseminated sclerosis. Brit. M. J. 2:1015,
1950.

8. Glaser, M. A.: Treatment of trigeminal neuralgia with tri-
chloroethylene. J.A.M.A. 96:916, 1931.

has gained considerably in popularity in this
country in recent years.

Trigeminal tractotomy in the brain stem, in-
troduced by Sjoqvist20 in 1938, is a rather formid-
able procedure. The results are not materially
better than those gained in other procedures
and do not justify the risks of this operation.

Compression rather than decompression of the
gasserian ganglion proposed by Shelden,21 simple
exposure of the ganglion with production of hy-
peremia as practiced by Stender,22 electrocoagu-
lation of the gasserian ganglion used by Kirsch-
ner,23 and section of the greater auricular nerve
advocated by Wybum-Mason15 have all been
used to limited extent with various degrees of
success and are still in the process of evaluation.

CONCLUSIONS

The proper management of the patient with
trigeminal neuralgia depends upon the patient’s
attitude towards his illness, the degree of severitv
of the disease in terms of discomfort and disabil-
ity, and the amount and extent of previous treat-
ment.

It is advisable to suggest a course of medical
therapy, that is, cyanocobalamin injections, to
the patient whose tic occurs at infrequent inter-
vals and does not materiallv interfere with his
normal activities. Alcohol injections of the offend-
ing branch should always precede surgical in-
tervention, but endless repetitions of this pro-
cedure rapidly reach the point of diminishing
returns. Effective surgical therapv in a patient
who has been adequately prepared for possible
complications of the operation, suggested at the
proper time in the course of the management,
will result in complete rehabilitation of the great
majority of severelv disabled patients.

There is no doubt that in most cases of tic
douloureux, patients should be prepared for
eventual surgical relief, since medical therapy is,
in most instances, of onlv temporary value.

9. Farmer, T. W.: Treatment of disorders involving the cranial
and peripheral nerves, in Modem Therapy in Neurology,
edited bv F. M. Forster. St. Louis: C. V. Mosbv Co., 1957.

10. Smith, G. W., and Miller, J. M.: Relief of tic douloureux
with stilbamidine. Ann. Int. Med. 38:335, 1953.

11. Hartel, F.: Die Leitungsaniisthesie und Injectionsbehandlung
des Ganglion Gasseri und der Trigeminusstamme. Arch. klin.
chir. 100:193, 1912.

12. Harris, W.: Analysis of 1,433 cases of paroxysmal trigeminal
neuralgia (trigeminal tic) and the end result of gasserian
alcohol injection. Brain 63:209, 1940.

13. Jaeger, R.: Permanent relief of tic douloureux by gasserian
injection of hot water. Arch. Neurol. Psvchiat. 77:1, 1957.

14. Peet, M. M., and Schneider, R. C.: Trigeminal neuralgia,
review of 689 ciises with follow-up study on 65 per cent of
group. J. Neurosurg. 9:367, 1952.

15. Wyburn-Mason, R.: Nature of tic douloureux; treatment by

32

THE JOURNAL-LANCET

Section on PAIN

alcohol block or section of great auricular nerve. Brit. M. J.
2:119, 1953.

16. Crue, B. L., Shelden, C. II., Pudenz, R. H., and Fresh-
water, D. B.: Observations on pain and trigger mechanism
in trigeminal neuralgia. Neurology 6:196, 1956.

17. Crawford, J. V., and Walker, A. E.: Surgery for pain, in:
A history of Neurological Surgery, edited by A. E. Walker.
Baltimore: Williams & Wilkens, Co., 19.51.

18. Spiller, W. G., and Frazier, C. H.: Division of sensory
root of trigeminus for relief of tic douloureux. Univ. Penn-
sylvania. M. Bull. 1-1:342, 1901.

19. Taarnh0j, P.: Decompression of trigeminal root and poster-

ior part of ganglion as treatment in trigeminal neuralgia. J.
Neurosurg. 9:288, 1952.

20. Sjoqvist, O.: Studies on pain conduction in trigeminal nerve;
contribution to surgical treatment of facial pain. Acta psychiat.
et neurol. (supp). 17:1, 1938.

21. Shelden, C. H., Pudenz, R. H., Freshwater, D. B., and

Crue, B. L.: Compression rather than decompression for

trigeminal neuralgia. J. Neurosurg. 12:123, 1955.

22. Stender, A.: “Gangliolysis” for surgical treatment of tri-

geminal neuralgia. J. Neurosurg. 11:333, 1954.

23. Kirschnf.r, M.: Die Punktionstechnik und die Elektrokoagu-
lation des Ganglion Gasseri; liber “gezielte” Operationen.
Arch. klin. Chir. 176:581, 1933.

Book Reviews on Pain

INTRODUCTION TO ANESTHESIA: THE PRIN-

CIPLES OF SAFE PRACTICE, by Robert D. Dripps,
M.D., professor and chairman, department of anes-
thesiology, Schools of Medicine, University of Penn-
sylvania and anesthetist, Hospital of the University of
Pennsylvania, Philadelphia; James E. Eckenhoff,
M.D., professor of anesthesiology, Schools of Medi-
cine, University of Pennsylvania and anesthetist, Hos-
pital of the University of Pennsylvania, Philadelphia;
and Leroy D. Vandam, M.D., clinical professor of
anesthesia, Harvard Medical School and director of
anesthesia, Peter Bent Brigham Hospital, Boston, 1957.
Philadelphia and London: W. B. Saunders Co., 266
pages.

All the authors of this work are well known and are
persons of authority in the field. What they have to
say represents accepted sound opinion. They cover the
field of anesthesia rather well, and they have included
useful information on the management of narcotic poi-
soning. They have made use of the most difficult but
most commendable literary technic of saying much in
few words, a technic which calls for a high degree of
accuracy. This requirement they have successfully sat-
isfied.

The book is printed on good paper, is easily read, and
is fairly well indexed. It is pleasant to come upon a
book as well done as this one. Anvone who is interested
in anesthesia should acquire the book.

John S. Lundy, M.D.

•

ANATOMIES OF PAIN, by K. D. Keele, M.D.,
F.R.C.P., 1957. Springfield/ Illinois: Charles C

Thomas, 206 pages. $5.50.

This book should become a classic and very likely it
will. Seldom does the reader experience such genuine
pleasure and even excitement from a book as are pro-
vided by this one. The work both stimulates thought
and enlarges one’s understanding of the ancient problem
of pain. The book would add greatly to the knowledge,
practical and cultural, of anyone interested in the sub-
ject of pain.

In his prefatory remarks, the author wisely observes,
“There appears to exist a widespread conviction that,
owing to the technical advances of the last century,
nothing of value can have existed previously that can
cast anv useful or revealing light on our present prob-
lems. The result is that historical introductions rarely

press further into the past than to a vaguely defined
‘Victorian era;’ and often with imperfect comprehension
even this far. A case in point occurs in a comprehensive
current work on the subject of pain, which by attrib-
uting the discovery of the spino-thalamic tract to Spiller
in 1905, ignores some fifty years of significant previous
work on this subject. To ignore the time dimension of
any problem is to risk misunderstanding it. Particularly
is this so if, as with regard to Pain, it involves neglect of
the keenest and most brilliant thinkers the world has
known.

“It is only of recent years that Pain itself has emerged
as a problem in its own right. Yet it has received spe-
cial attention as part of disease from the earliest dawn
of civilization. It is the purpose of this book to show
how the changing ideas on the anatomical and physio-
logical basis of Pain have flowed as a continuous process
from the most ancient medicine until the present day.
To attempt this is not to attempt a complete history of
the subject, but only to trace the growth of anatomy and
physiological concepts which lie, often unconsciously, at
the roots of our present ideas. To achieve such an in-
tegration I have necessarily been selective of those
writers whose works are for the most part well known,
for their influence has been greatest. Though authorities
have been omitted whose names rightly carry much
honor in the history of medicine, I have included all
those I have found who made significant contributions
to the process of the evolution of the subject.

“It is my own conviction that ‘right thinking’ is an
impersonal mode of mental activity in the Buddhist
sense; and that thinkers like Aristotle or Leonardo da
Vinci achieve exquisitely intimate interpretations of ob-
served phenomena, outstripping humbler thinkers, when-
ever they are born. However, one of the clearest lessons
to be learned from such a survey is that it is not enough
to have the right ideas; if they are to be fruitful of
results, thev must be produced at the right time, when
there is sufficient contextual background to support them.
It was just this failure of the intellectual milieu of his
dav that gave Leonardo’s right ideas such poor fruit,
leaving him in so manv fields merely the ‘anticipator’
rather than the recognized ‘discoverer.’

“In this book there will be found a story of anticipa-
tions needing firmer ground to raise them to discoveries.
Some have achieved such status already; others await it.

( Continued on page 34 )

JANUARY 1958

33

Editorial

A COMMON PAIN AND AN
UNCOMMON PROBLEM

Among the many common pains which may
visit the head, tic douloureux is one of the
most severe. This pain is so disabling that any-
thing which can be done to alleviate it is emi-
nently worth while. In fact, this type of pain is
so stubborn that the subject itself never becomes
old. It is treated in this issue by Dr. Charles M.
Poser under the title of “The Management of Tic
Douloureux.”

In the October 1957 issue of the Section of
Pain, I pointed out that I had been able, by
means of the combined use of several new agents,
to develop a plan to assist those who are doing
cardiac catheterization in children too young to
cooperate. Mv experience at that time was not
very broad. It still is not too extensive, but I
did describe in more detail in the November
1957 issue of the Journal of American Association
of Nurse Anesthetists' how this was managed.
Much more detailed instructions having to do
with this problem will appear soon, I hope, in
the Journal of the American Medical Associa-
tion.-

The present editorial was written on Decem-
ber 11, 1957. To that date I had carried out the

REFERENCES

1. Lundy, J. S.: New Methods for the conquest of pain through
use of antagonists and a new management of analgesia-
amnesia for cardiac catheterization in children too young to
cooperate. J. Am. A. Nurse Anesthetists. 25:221, 1957.

procedure for 34 patients, and, in general, the
method has been very satisfactory. I am in the
process of making it easier to measure the dose
of the drugs required. One drug, alphaprodine
hydrochloride (Nisentil hydrochloride) was sup-
plied by the manufacturer in the proportion of
60 mg. to the cubic centimeter of solution, a pro-
portion which made it almost impossible to mea-
sure a dose that would be minute enough to ad-
minister to a small baby. The proportion of this
agent to its solution will be corrected in the fu-
ture, I am sure.

As for the procedure itself, I have also used
it for two or three patients who were to under-
go examination of the eyes. It permitted ex-
amination adequate for arrival at a diagnosis-
something which has been difficult heretofore.

I think it is worth repeating that sometimes
better results can be obtained with drugs which
produce only analgesia and amnesia than with
drugs used in a dose large enough to produce
anesthesia. Cyanotic patients who have under-
gone cardiac catheterization have ranged from
15 months to 14 years and from 15 to 90 lb.
There may be other uses for this particular
method, but thus far we have not tried others.
The editor would appreciate comment about
other methods of managing these small children
during the diagnostic maneuver concerned.

John S. Lundy, M.D.

2. Lundy, J. S.: Method of producing amnesia-analgesia for

management of children too young to co-operate undergoing
cardiac catheterization and other procedures. J.A.M.A. (In
press. )

BOOK REVIEWS

( Continued from page 33 )

Perhaps one of the most topical of such anticipations is
the concept of the sensorium commune, which, far from
being an idea of our Victorian ancestors (as stated in a
current medical journal), is traceable back to the most
ancient thinkers on the nature of sensation, and now ap-
pears due for rebirth.

“It is my hope that present-day workers on Pain will
find in these Anatomies of Pain a useful background to
the problem, and possibly some still fertile seeds from
the past worthy of germination.

“To avoid the manifest risk of errors inherent in para-
phrasing views of ancient authorities, 1 have freely
quoted from their works. This however does not obviate
the erroneous significance which may be attached, for
example, to Aristotle’s often quoted description of pain
as a ‘passion of the soul,’ which words cannot be intel-
ligible without some background of Aristotelian physi-

ology. I have therefore endeavored to introduce each
authority’s views on pain with a sketch of his concept of
the basis of sensation sufficient to render the quotations
comprehensible.

“It has been my endeavor to render these accounts as
objective as possible in all chapters, with the exception
of the last, in which I have allowed myself to express
a more personal interpretation of the present anatomy
of pain.”

It is fascinating indeed to be taken back oxer the years
on a scientific Pegasus in a sort of guided tour of the
various anatomic and physiologic monuments to signifi-
cant thought in the understanding of pain mechanisms.

The book is printed on good paper and can be easily
read. It contains two indices — one on subjects and one
on personal names. Each chapter is well documented
with a bibliography. In sum, this book is a magnificent
contribution to the literature on pain.

John S. Lundy, M.D.

34

THE JOURNAL-LANCET

Section on PAIN

Current Literature on Pain

ANALGESICS AND THEIR ANTAGONISTS: SOME
STERIC AND CHEMICAL CONSIDERATIONS.
PART III. THE INFLUENCE OF THE BASIC
CROUP ON THE BIOLOGICAL RESPONSE, by
A. H. Beckett, A. F. Casy, and N. J. Harper: j.
Pharm. & Pharmacol. 8:874-884, 1956.

“Elsewhere the thesis was advanced that the basic group
of the molecule influenced analgesic activity and evidence
, was adduced in support. In morphine-type compounds,
a gradual transition from analgesic to anti-analgesic activ-
ity occurred as the group was changed from N-mcthyl
to N-ethyl, N-n-propyl and N-allyl .... It seems rea-
sonable to assume that the mechanism of action of an
! analgesic antagonist involves competition with an anal-
1 gesic for the ‘analgesic receptor site,’ but ‘fit’ at the re-
ceptor surface does not of necessity mediate an analgesic
response ....

“The hypothesis is advanced that analgesics and their
j antagonists undergo a similar chemical reaction subse-
quent to adsorption, the rate constant for the former be-
ing very much greater than that for the latter. Oxidative
dealkylation to produce nor-compounds is presumed to
be the first step in the reaction sequence leading to anal-
gesia. Nor-morphine has been shown to have a greater
I analgesic activity than morphine upon intracisternal in-
j jection into mice.”

jl From John S. Lundy and Fi.orence A. McQuillen: Anesthesia
1 Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 19. Copyright by John S. Lundy.

FATALITIES FOLLOWING TOPICAL APPLICATION
OF LOCAL ANESTHETICS TO MUCOUS MEM-
BRANES, by J. Adriani and D. Campbell: |.A.M.A.

162:1527-1530, 1956.

j “It is surprising that many physicians are unaware of the
hazards of local anesthesia. The pioneers in this field
recognized and emphasized the pitfalls that residt from
the misuse of local anesthetic drugs .... Accurate
statistics on the frequency of untoward reactions and
j fatalities due to local anesthetics are not available, be-
cause few such mishaps are reported. We are familiar
with 10 unreported fatalities in a 15-year period in this
institution [Charity Hospital, New Orleans] caused by
the topical application of tetracaine to mucous surfaces
| for endoscopic procedures ....

“It is the intent of this report to emphasize the extreme
potency and relative frecpiency of toxic effects from tet-
racaine and not to incriminate the drug as a lethal sub-
stance that should be discarded .... The major dis-
tinction between reactions due to tetracaine and those of
the other aforementioned drugs has been the absence of
convulsions and the abrupt opset of syncope. The inter-
val between the onset of symptoms and the moment of
the fatal termination was brief .... The incidence of
l reactions with use of tetracaine by other routes has been
considerably less than with the topical route ....

“Rapid absorption has been presumed as the cause,
but data in support of this contention have not been
available. Studies of blood levels of tetracaine indicate
that this occurs and at a more rapid rate than has been
supposed. A quantity of drug that results in no detect-
j able blood level when infiltrated subcutaneously gives
j levels when applied topically that are equal to one-third
to one-half of those after intravenous injection. The un-

toward responses are due to the rapid passage of the
drug from the site of application into the systemic circu-
lation. The absorption from mucous membranes is far
more rapid than clinicians have realized and simulates
intravenous administration. Study of the fatalities that
have occurred indicates that the cause of death is over-
dosage from rapid absorption.”

From John S. Lundy and Florence A. McQuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 4. Copyright by John S. Lundy.

CORTISONE AND ANESTHESIA, by S. W. Corens:

J. Am. A. Nurse Anesthetists 24:259-264, 1956.

“Evidence exists to indicate that with more prolonged
administration of cortisone, suppression of adrenal cor-
tical function may persist for as long as 3 to 6 months
after the use of the hormone is discontinued .... The
patient may show evidences of adrenal insufficiency at
induction of anesthesia .... during the course of sur-
gery or in the immediate postoperative period. The first
and possibly only evidence of acute adrenal insufficiency
is otherwsie unexplainable cardiovascular collapse with
shock, tachycardia, pallor, etc

“The pituitary-adrenal interrelationship .... is al-
tered by the exogenous administration of cortisone so
that as a result you may get adrenal atrophy and insuf-
ficiency. That with the stress of anesthesia and surgery,
adrenal response may be inadequate and you may get
collapse, shock and death. In view of the ever increasing
number of individuals who are and will be receiving
cortisone and may have potential adrenal insufficiency,
it is important that anesthesiologists and surgeons be
aware of the dangers and be prepared to handle any
emergency situation that may arise in this regard.”

From Lundy, John S., and McQuillen, Florence A: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 73. Copyright by John S. Lundy.

•

THE ASSESSMENT OF THE CARDIAC PATIENT

FOR ANAESTHESIA, by A. J. W. Beard and J. F.

Goodwin: Brit. J. Anaesth. 28:557-568, 1956.

“Patients with cardiac disorders present the anaesthetist
with three main problems which are related to ( 1 ) the
operation itself, (2) the ability of the patient to with-
stand operation or any of its complications, and (3) the
selection of the anaesthetic agent and technique ....
A close rapport between anaesthetist and surgeon, and
their joint understanding of the physiopathologv of heart
disease makes for greater safety ....

“The cardiovascular state may be such that even an
urgent condition such as an operable neoplasm must re-
main untreated, but this is unusual, as, given time for
treatment of such conditions as congestive heart failure
or for the healing of a recent cardiac infarction, surgery
can often be carried through with little increased risk.
The control of cardiac rhythm and rate, the correction of
sodium and water retention, the treatment of anaemia,
the prevention of pulmonary infections, and weight re-
duction in obesity can so change the picture as to allow
the completion of even radical surgery ....

“Hvpoxia is the greatest danger to which the cardiac
patient is exposed during surgical operation. It is often
associated with other pathological conditions, such as
heart failure or hypotension, either as cause or effect.

JANUARY 1958

35

Section on PAIN

Hypoxia must therefore be considered in relation to such
states rather than as an isolated condition ....

“Ordinarily hypoxia is associated with carbon dioxide
retention which in moderate excess causes tachycardia;
gross carbon dioxide excess, however, impairs the con-
duction in the bundle of His, producing heart block and
slow ventricular rate. Furthermore, carbon dioxide re-
tention increases cardiac irritability and, especially in the
presence of cyclopropane or chloroform, cardiac irregu-
larity may be so gross as to impair the circulation ....

“Hypoxia may also result from anaemia. The danger of
circulatory overloading is well recognized, especially in
heart conditions associated with left ventricular failure,
mitral stenosis, or pulmonary heart failure. Any trans-
fusion to remedy the anaemia must be given slowly, and
the use of packed red blood cells is advisable. The use
of iron, perhaps given intramuscularly, may sometimes
make transfusion unnecessary ....

“In order to reduce the oxygen consumption of the
tissues, hypothermia may be used, but it carries a greater
liability to ventricular fibrillation with increasing age and
in the presence of heart disease .... On the other
hand, the avoidance of hyperthermia, or even permitting
a few degrees of cooling, is of considerable benefit ....

“The blood pressure is maintained by the cardiac out-
put and the total peripheral resistance. The total periph-
eral resistance depends on the state of constriction or
dilatation of the arterioles. If these are dilated the blood
pressure will fall .... There is not yet agreement as
to the circulatory effects of the generally accepted anaes-
thetic sequences .... While there are difficulties in
assessing the haemodynamics of anaesthetic agents in
experimental animals and in healthy men, there is, for
obvious reasons, very little precise information from pa-
tients with cardiac disease ....

“The risk of anaesthesia often depends as much upon
the experience and skill of the anaesthetist and the pre-
operative degree of cardiac efficiency as upon the type
of heart disease .... In general, the risks to which the
patient with cardiac disease is exposed depend on the
nature of the proposed operation and its possible com-
plications and on the general cardiovascular status of the
patient. The type of anaesthetic, provided it is com-
petently administered and conforms to basic principles,
together with the specific nature of the cardiac disability
is usually of lesser importance. Nothing overrides the
truth that techniques and disease processes which impair
the oxygen supply to the heart are always a threat to
life.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 16-18. Copyright by John S. Lundy.

•

PEDIATRIC ANESTHESIA, by L. D. Bridenbauch,
Jr.: J. Am. A. Nurse Anesthetists 24:155-163, 1956.
“Anesthetists who have had limited experience in admin-
istering anesthesia to children are still proceeding on the
theory that children are ‘just small adults,’ and that if an
anesthetic agent is appropriate for an adult, it is also
appropriate for a child. However, certain anatomical and
physiological characteristics peculiar to the child must
be recognized and, accordingly, the amount of anesthetic
agent and the technique of administering it must be suit-
ably altered ....

“Variations between the respiratory system of the child
and that of the adult are of the utmost importance to the
anesthetist. These include — Resilience of the bony part

of the thoracic cage, .... Incomplete development of

the lung tissue, Increased respiratory rate .... |

and Small tidal volume ....

“Peculiarities of the child’s cardiovascular system, im-
portant to the anesthetist, include — Inherent automatici-
ty, . . . . Increased heart rate, .... (and) Low blood
pressure, .... Blood loss during surgery is tolerated
poorly by infants because they have a small blood volume :
( roughly 80 cc. per Kg. ) and are naturally hypotensive, i
“The central nervous system of the infant also presents
variations from that of the adult. Most of them are due I
to the immaturity of the nervous tissue and result in —
Decreased sensation, .... and Increased incidence of
convulsions, . . . .The heat regulating centers of the in- >1
fant are immature ....

“The anesthetist should check to see that the patient
to be anesthetized has an empty stomach. Aspiration of
vomitus is as serious a complication in the child as it is
in the adult .... During the course of anesthesia an
infant frequently develops an acute distention of the
stomach. The cause for this is unknown .... The
child’s kidney is much less capable of dealing adequately
witli excess amounts of saline than is the adult’s kidney.

“A plea is made for those administering children’s
anesthesia to use the drugs and techniques with which
they are most familiar and to use them cautiously. If
this is done, pediatric anesthesia will truly be ‘anesthesia
without tears’ — on the part of both child and parents.”

From John S. Lundy' and Florence A. McQuillen: Anesthesia I
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, pages 28-29. Copyright by John S. Lundy*.

•

CONTRIBUTION TO THE THERAPY OF MYOCAR-
DIAL DEPRESSION CAUSED BY THIOPENTONE
SODIUM (STUDIED BY HIGH FREQUENCY CAR-
DIOMYOGRAPHY), bv A. Fronek and Z. Pisa: J.
Anaesth. 28:366-372, 1956.

“A fall in blood pressure occasionally occurs during
intravenous anaesthesia with various barbiturate prepa-
rations .... In the studies to be reported, there have
been analysed more closely the factors causing lowering
of the blood pressure during intravenous anaesthesia with
sodium thiopentone and we have attempted to influence
this decrease in pressure therapeutically. The effect of
this therapeutic intervention on the depth and duration
of anaesthesia has also been investigated .... Experi-
ments were carried out in a total of 15 dogs ....

“A weakening of ventricular contraction during intra-
venous administration of thiopentone has been demon-
strated with high frequency cardiomyography. A direct
depressant action on myocardial muscle by this drug has
also been demonstrated following its intracoronary ad-
ministration. It has been found that falls in blood pres-
sure caused by thiopentone are immediately reversible
by the intravenous administration of 5 to 10 ml. of
10 per cent CaCL.

“The intravenous administration of CaCL affects nei-
ther the duration nor the depth of anaesthesia in rabbits.

It has been emphasized that these findings may be of
some importance by increasing the safety of intravenous
barbiturate anaesthesia: (1) in patients with latent or
manifest ischaemic myocardial diseases; (b) in patients
in shock; (c) in cases of accidental overdosage or when
more toxic preparations are used.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 67. Copyright by John S. Lundy-.

36

THE JOURNAL-LANCET

symptomatic relief ... plus!

*pl I 111

achrocidin is a well-balanced, comprehensive formula for
treating acute upper respiratory infections.

Debilitating symptoms of malaise, headache, pain, mucosal
and nasal discharge are rapidly relieved.

Early, potent therapy is offered against disabling complications
to which the patient may be highly vulnerable, particularly
during febrile respiratory epidemics or when questionable middle
ear, pulmonary, nephritic, or rheumatic signs are present.

achrocidin is convenient for you to prescribe — easy for the
patient to take. Average adult dose: two tablets, or teaspoonfuls
of syrup, three or four times daily.

tablets

ACHROMYCIN ® Tetracycline

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Each teaspoonful (5 cc.) contains:
ACHROMYCIN ® Tetracycline

equivalent to tetracycline HC1 125 mg.

Phenacetin 120 mg.

Salicylamide 150 mg.

Ascorbic Acid (C) 25 mg.

Pyrilamine Maleate 15 mg.

Methylparaben 4 mg.

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' Keg. U. S. Pet. Off.

23 A

The Diagnosis and Treatment of
Endocrine Disorders in Childhood
and Adolescence, by Lawson
Wilkins, M.D., ed. 2, 1957.

Springfield, Illinois: Charles C

Thomas. $17.50.

This is a thorough revision of the
first edition of Dr. Wilkins’ excel-
lent textbook. In addition, the text
and illustrations have been expand-
ed considerably. The author has
done an excellent job in bringing
this book up-to-date at a time when
progress in this field has been very
rapid. Although not intended to be
a thorough treatise of every endo-
crine disorder in children, it is
without doubt the best available
source from which to start complete
coverage of any facet of endocrinol-
ogy in childhood. The notable ex-
ception is that diabetes in children
is not included. Now included is
the latest information on the steroid
physiology and clinical aspects of
diagnosis and treatment of the ad-
renogenital syndrome. The author
and his co-workers have been lead-
ers in this field, and their very val-
uable experience is documented in
a clear-cut, easily read section. In
addition, a new section is devoted
to the newer knowledge regarding
the “goiterous cretins.” An entire
new chapter has been included to

REVIEWS

familiarize the practitioner with new
diagnostic laboratory hormone de-
terminations. The purpose of this
chapter appears to be to familiarize
the clinician with the intelligent use
of these tests rather than to serve as
a laboratory manual. Such a pur-
pose is quite well fulfilled.

Each chapter of this book is writ-
ten in essentially the same form as
the first edition, although most
chapters have not only been revised
and brought up-to-date but also en-
larged. Very little material is in-
cluded that is not essential to the
understanding of the conditions dis-
cussed. The style creates a logical
sequence of written presentation and
is accompanied by fine illustrations.
The number of illustrations also
have been increased and are repro-
duced in excellent quality. The use
of schematic diagrams as well as

pertinent summaries of the illus-
trated pictures gives one the im-
pression of having worked with the
patient himself.

This book cannot be recommend-
ed too highly to any physician who
deals with children, including those
in the sub-specialties. It is also
recommended to owners of the first
edition, because so much new ma-
terial essential to understanding the
rapid advances which have been
made has been added since this
book was first published.

Robert Ulstrom, M.D.

•

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Wolstenholme and Elaine C.
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This volume should be brought to
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interested in the mode of action of
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supported by Ciba Ltd., of Switzer-
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presenting chiefly physiologic as-
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pertinent bibliography followed by
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•

The Surgical Management of Pul-
monary Tuberculosis, edited bv
John D. Steele, 1957. Spring-
field, Illinois: Charles C Thomas,
213 pages. $9.50.

This monograph is the first of a
series concerned with various phases
of thoracic surgery and dedicated to
Dr. John Alexander. It is fitting that
this initial volume should be con-
cerned with a subject to which Dr.
Alexander contributed so greatly,
and most of the participants are his
former residents. It is a reasonably
short but complete presentation of
current concepts regarding the sur-
gical treatment of pulmonary tuber-
culosis. The initial chapters trace
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ters outline the indications for vari-
ous types of resections and give
morbidity and mortality figures.
Combined collapse and resection
therapy is discussed, as is plombage
and the treatment of pleural tuber-
culosis. An interesting chapter on
thoracoplasty indicates the general
trend away from such a procedure
as an isolated form of surgical ther-
apy, although its use as an adjunct
either before or after resection is
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cases are pointed out, and such pro-
cedures appear to have considerable
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Urology and Industry, by Leonard
Paul Wershub, 1956. Spring-
field, Illinois: Charles C Thomas,
151 pages, 3 parts. $5.00.

The purpose of this book, as stated
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The evolution of industrial medi-
cine and Workmen’s Compensation
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liability. In the third part, 100 in-
dustrial urologic cases and their le-
gal connotations are adequately pre-
sented. Three typographical errors
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be vesical; on page 86, prostatis
should be prostatic; and on page
94, diverticuli should be diverticula.

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cerned with a subject with which
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industrial physician and urologist.
The bibliography is adequate.

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SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

The Treatment of Diabetic Acidosis

EDMUND B. FLINK, M.D., and THOMAS K. OLWIN, M.D.
Minneapolis, Minnesota

A brief review of the pathogenesis of diabetic
ketosis will be made in order to outline a
rational basis for therapy. The reader is referred
to the most recent Medical Progress review of
diabetes mellitus by Beaser.1

Diagnosis requires a clear definition of diabetic
acidosis and coma and adherence to strict cri-
teria. A state of coma, that is, a profound state
of unconsciousness, may occur in a diabetic
patient, as in any other person, without being
related to diabetic acidosis. The other most im-
portant cause of a comatose state in diabetic
patients is hypoglycemia. Many tragedies have
resulted from confusing hypoglycemia with dia-
betic acidosis, since the former is one of the most
i serious medical emergencies and must be treated
immediately. Other causes include head trauma,
cerebrovascular occlusions, meningitis, encepha-
litis, and brain tumor. Any of these conditions
could also be the precipitating factor in acidosis.

Because of these considerations, a diagnosis
of diabetic acidosis should not be made and in-
tensive treatment should not be given unless the
following criteria are present: ketonemia and
hyperglycemia (and, usually, ketonuria and gly-
cosuria), decrease of carbon dioxide content or
capacity to less than 15 mEq./l., and clinical
evidence of acidosis and dehydration. Milder
ketosis than this needs prompt treatment with

edmund b. flink is chief of the Medical Service
at Veterans Administration Hospital, Minneapolis.
thomas k. olwin is with the Department of Medi-
\cine at Veterans Administration Hospital.

insulin and other measures but doesn’t require
the heroic treatment which will be discussed in
detail. Obviously, prevention of severe acidosis
by the early treatment of ketosis is better than
the best later management of severe acidosis.

PATHOLOGIC PHYSIOLOGY OF DIABETES ACIDOSIS

Lack of insulin is of prime importance and re-
sults in impaired glycogenesis, increased glvco-
genolysis, and failure of the glycolytic cycle. This
causes insufficient pyruvic acid production and
disturbance of metabolic equilibrium with keto-
nemia and ketonuria (acetone, aceto-acetic acid,
beta-hydroxybutyric acid). The ketonemia and
ketonuria, the hyperglycemia and glucosuria, in
turn, result in polyuria, cellular and extracellu-
lar dehydration, loss of electrolytes, and acidosis.
These processes develop as a chain reaction and
can be reversed only by adequate insulin and
replacement of fluids and electrolytes which
have been lost. The lack of insulin may be due
simply to failure to administer it, an increased
demand due to infection, stress, and so forth,
or to previously unrecognized diabetes. It is
important to ascertain immediately the precipi-
tating factor in each instance.

Three studies have defined clearly the very
large fluid and electrolyte deficits which occur
in diabetic acidosis.3-5 Two of these studies re-
cord the cumulative negative balances during
production of acidosis by insulin withdrawal,
and the third records balance studies of a group
of 5 patients during recovery from acidosis.
Table 1 summarizes the findings of these studies.

TABLE 1

Atchley

Butler

Nabarro

Body size

58 kg.

68 kg.

1.73 sq.m.

Water, liters

3.8

6.6

5.5

Sodium and

magnesium, mEq.

216.

Sodium, mEq.

322.

428.

Magnesium, mEq.

50.

40.

Potassium, mEq.

362.

388.

339.

Chloride, mEq.

42.

272.

390.

Phosphorus, gm.

4.6

5.

1.13

Severe enough acidosis developed on the
fourth day in the patient of Atchley and associ-
ates3 so that the experiment was stopped at a
time when the C02 was 14.6 mEq./l. The data
recorded in table 1 were actually observed. The
observations of Butler and associates4 are part-
ially derived data in that theoretic losses from
severe acidosis are added to those actually ob-
served and are included, since the acidosis was
not permitted to progress to a serious point. The
data of Nabarro and associates5 are the actual
cumulative balances from 5 patients being treat-
ed for diabetic acidosis. These latter data, there-
fore, are the most representative, but the close
similarity of all 3 studies is very impressive. It
is noteworthy that the extracellular losses repre-
sent from 20 to 25 per cent of the total extracellu-
lar volume and that the potassium loss repre-
sents 8 to 9 per cent of body stores.

If one uses 70 kg. as the weight of a 1.73
square meter person (Nabarro study), the aver-
age losses in Butler s and in Nabarro ’s studies
can be expressed as follows on a per kg. basis.

Butler

Nabarro

Water, ml. /kg.

100.

80.

Sodium, mEq. /kg.

5.

6.

Chloride, mEq. /kg.

4.

5.5

Potassium, mEq. /kg.

6.

5.

Magnesium, mEq. /kg.

0.8

0.6

Phosphorus, mg. /kg.

70.

15.

It is evident from Nabarro's detailed data that
there is quite a bit of variability in certain items,
particularly in nitrogen and phosphorus. It is
also clear that mild acidosis of short duration

is associated with much smaller cellular ion
losses but often nearly maximum extracellular
fluid losses. The importance of these studies can-
not be overestimated, for they permit us to make
a reasonable calculation of the requirements of a
patient with diabetic acidosis. The studies em-
phasize the fact that large quantities of both
intracellular and extracellular ions are lost.

The recognition of fatal respiratory paralysis
due to hypopotassemia during the course of
treatment of diabetic acidosis6 marked a mile-
stone in the understanding of potassium metabol-
ism. Many cases have been reported since then
of serious hypopotassemia. In spite of their con-
certed effort to prevent hypopotassemia, Smith
and Martin” found that the largest single cause of
death in their series was hypopotassemia, since
inadequate amounts of potassium were adminis-
tered in some cases. “Some” potassium is not
sufficient, hut at least 1/3 and preferably 1/2
of the theoretic deficit is necessary in the first
twelve to sixteen hours.

A brief case report bears out the need for
vigorous therapy. This patient, age 23, had class-
ical symptoms of diabetes mellitus for three
weeks and then acidosis developed. His treat-
ment for the first forty-eight hours at another
hospital and for the next forty-eight hours at this
hospital is outlined in table 2.

He was admitted to the Minneapolis Veterans
Hospital because of progressive weakness to the
point of severe generalized paresis. Some cloud-
ing of sensorium and typical electrocardiographic
changes of hypopotassemia were noted on ad-
mission. Unnecessarily large amounts of sodium
salts were administered during the second fortv-
eight-honr period. The ready-made solution used
in this instance had an inadequate concentration
of potassium for the treatment of a known potas-
sium deficit. Such solutions are adequate only
for daily maintenance unless an ampule of po-
tassium salt is added.

Nabarro and co-workers5 emphasize the fact
that bowel function and a feeling of well-being
were brought to normal more rapidly when ade-
quate potassium was supplied early in treatment.
The transfer of sodium into cells when potassium

TABLE 2

J.T.W., 23

Insulin

Water

Na.

Cl.

Lactate

K.

Mg.

HPOi

Rx. first 48 hours
Paralysis
Serum K. 1.9

1,200

7,000

481

460

75

75

18

37

Rx. second 48 hours
Strength good
Serum K. 3.2

6,000

579

745

50

230

12

25

38

THE JOURNAL-LANCET

was not used can be prevented to a large extent
by use of potassium. They emphasize the fact
that potassium (and probably also magnesium
and phosphate) are indicated for general meta-
bolic functions of cells and not simply for pre-
vention of an occasional instance of cardiac
arrhythmia or respiratory paralysis.

THERAPY

General measures. Diabetic acidosis must be re-
garded as a major medical emergency. A physi-
cian should be in attendance all the time. Local
infections of the skin, ears, respiratory or urin-
ary tract, and systemic infections should be look-
ed for and treated adequately with antibiotics.
A detailed history of the diabetes from an in-
formant, if necessary, should include information
about insulin dosage and sensitivity, other epi-
sodes of coma, precipitating episodes, and so
forth.

A chart of the important clinical and chemical
data is imperative. This chart should include:
pulse, blood pressure, state of consciousness,
urine volume, urine sugar, urine acetone and di-
acetic acid, blood glucose, carbon dioxide ca-
pacity, sodium, potassium, plasma acetone, blood
urea nitrogen; therapy: insulin, fluid volume,
sodium, potassium, chloride, lactate (or bicar-
bonate), phosphate, magnesium, glucose; and
space for comment on associated illnesses. It is
important to keep this chart current.

Each chart must be individualized, but a few
generalizations can be made. Some data, such
as vital signs, should be cheeked every half hour
and oftener if shock exists, of course. Urinalysis
should be recorded hourly. Plasma acetone and
blood glucose can profitably be checked every
two hours until recovery is well under way. The
carbon dioxide combining power could be check-
ed at six hours, but, if the course is favorable
clinically, it need not be determined again. In
order to detect hvpopotassemia, serum shoidd be
obtained six to twelve hours after starting insulin
for optimum results.

When the initial serum potassium is normal in
a patient with severe acidosis and, especially,
when the blood urea nitrogen is elevated, the

need for potassium is greater, and therapy must
be started earlier and given more vigorously.
Serial electrocardiograms from the start of ther-
apy are particularly valuable as an aid to potas-
sium administration, since the information is
immediately available. A single lead, such as V:!,
is all that is needed for these comparative pur-
poses and should be obtained every hour or two.

A severity index8 may be calculated from the
data charted to roughly determine the prognosis,
but it is more important to alert the physician to
the need for vigorous therapy because of un-
favorable signs. Such an index, furthermore, has
the real advantage of calling attention to the
most important unfavorable variables, some of
which are often ignored in routine management.
Zieve and Hill8 concluded their study as follows:
“considered individually, the order of effective-
ness of the significant prognostic variables was
age, blood pressure (i.e. hypotension), associated
conditions, blood urea nitrogen, degree of un-
consciousness, and duration of coma.” The need
for individualizing treatment according to sever-
ity of illness is strongly suggested by the statisti-
cal study of Zieve and Hill.9 They found no
significant differences in treatment in spite of
great differences in severity of illness. As shall
be apparent later, there appears to be a particu-
lar need for individualizing the dose of insulin.
The score can easily be calculated from table 3. 8

Zero is the dividing line between those who
have a poor prognosis (negative score) and those
who have a better prognosis (positive score).
The quantitative value of term I is obtained di-
rectly from table 4.

Insulin. The insulin dose used is the subject
of considerable controversy. Smith and Martin7
found that there was no significant difference in
response of patients given 80 units, 160 units, or
240 units initially and every two hours thereafter
until hyperglycemia decreased significantly. To
the contrary, however, others believe that an in-
crease in insulin dosage has been responsible for
great improvement in morbidity and mortal-
ity. 10-1 - The following doses were used in a large
group of patients who were treated at the Joslin
Clinic (table 5).

TABLE 3

SUMMARY OK INFORMATION NEEDED TO CALCULATE SEVERITY SCORE

Severity score = 1 + 11 — III

I = ( 14 AC + 7 DU) AC = associated condition

DU = degree of unconsciousness

II = (0.3 BP + 0. 1 BS) BP = mean blood pressure (S + D)/2

BS = blood sugar, mg./ 100 cc.

Ill = (DC + BUN + 44) DC = duration of coma/hr.

BL^N = blood urea nitrogen. mg./lOO cc.

FEBRUARY 1958

39

TABLE 4

RATING OF AC

0

i

2

3 4

5

§ 0

27.9

14.5

7.6

2.0 —4.6

—15.6

fc 1

21.4

8.1

1.1

—4.4 —11.0

—22.0

o 2

15.6

2.2

—4.7

—10.2 —16.9

—27.9

2 Q

H °

10.2

—3.2

—10.1

—15.6 —22,3

—33.3

2 4

4.2

—9.2

—16.1

—21.6 —28.3

—39,3

Rating scheme of AC

Rating scheme of DU

0 None

0 Conscious and alert

1 Very mild

1 Drowsy

2 Mild

2 Semiconscious

3 Moderately

severe

3 Unconscious but responds to pain

4 Severe

4 Unconscious and unresponsive

5 Very severe

TABLE 5

BLOOD SUGAR

LEVEL CORRELATED WITH INSULIN DOSE IN 153 COMA CASES

Blood sugar

Average insulin

Average insulin

on admission

in first 3 hours.

in first 24 hours.

mg. per 100 cc.

Cases

units

units

1,300-1,600

2

800

1,775

1,000-1,300

12

490

826

600-1,000

51

317

482

400-600

46

224

370

200-400

40

110

155

100-200°

2

56

123

•Low values due to administration of insulin on way to hospital

Duncan12 recommends the following initial
doses of insulin according to the severity of the
acidosis as measured by plasma acetone reaction:

Initial insulin dose

Plasma acetone test

100 units

4+ undiluted

200 units

4-f 1-2 diluted

300 units

4-f 1-4 diluted

400 units

4-f 1-8 diluted

Following the initial doses, as much as 100 units
is given every half hour until plasma acetone
is less than 4-f in undiluted plasma.

In a review of 25 instances of diabetic acidosis
studied at this hospital, the average doses used
were:

Initial
blood sugar

Average insulin dosage
Total

6 hours 24 hours

1

1,136

475

725

1

660

100

160

12

400-600

255

374

10

296-400

195

248

1

396

780

1,030

Total 25

296-1,136

262

355

The group of patients treated is too small to
draw many conclusions from the study. Review- I
ing the charts individually indicated inadequate
early insulin dosage in some. One patient singled
out for attention had a blood sugar of 396. He I
received invert sugar in large amounts almost
from the start of therapy with the result that
hyperglycemia was prolonged, and he received
what would otherwise have been an unnecessar- I
ily large dose of insulin.

The initial dose of insulin should be large and
can be given intravenously or half intravenously
and half subcutaneously. Unless there is a his- i
tory of marked insulin sensitivity, the initial dose
should be 100 units. If the blood glucose is over
700-mg. per cent, the initial dose should be 200
units, and if the blood glucose is over 1,000 mg./
per cent, it should be 300 units. Depending on
the severity of the acidosis, a dose of 50 to 100
units should be repeated every half hour for two
hours. The most important consideration is the
close observation of the glucose response to in-
sulin in the first four hours. Failure to respond
in this time calls for increase in insulin dose.

Fluid and electroh/tes. The following fluid re-
placement therapy for an average sized adult is

40

THE JOURNAL-LANCET

TABLE 6

Fluid

Electrolytes to be added

1. 1,000 cc. distilled water

2. 1,000 cc. distilled water

3. 1,000 cc. 5% glucose

4. 1,000 cc. 5% glucose

5. 1,000 cc. 5% glucose

Two 44 mEq. (3.75 gm.) ampules NaHCCL and one 50 mEq. (2.92 gm. ) vial NaCl.
One ampule NaIICO;, and two vials NaCl.

One ampule NaCl. and one 40 mEq. (2.98 gm.) ampule KCL.

One ampule NaCl., 40 mEq. ampule KJIPO,, and 2 gm. MgSO, (17 mEq. Mg.++).
One ampule K-HPO., one 20 mEq. ampule KCL, and 2 gm. MgSO,.

TABLE 7

Water

Na.

Cl.

HCOs

K.

HPOn

Mg.

Glucose

1.

1,000 cc.

139

50

89

2.

1,000 cc.

144

100

44

3.

1,000 cc.

50

90

40

50 gm.

4.

1,000 cc.

50

50

40

40

17

50 gm.

5.

1,000 cc.

20

60

40

17

50 gm.

Total mEq.

383

310

133

140

80

34

based on knowledge of average losses. Of course,
this therapy has to be individualized. Concen-
trated ion solutions can be added to a liter of
water to make up the solutions as shown in
table 6. These solutions will provide the elements
shown in table 7.

Appropriate adjustments of these amounts can
easily be made for smaller adults and for child-
ren. Children require relatively more water, and
this can be accomplished by giving somewhat
more dilute solutions. Usually, the patient is
able to begin oral feeding, including potassium,
after this amount of fluid has been given, hut
some patients require continued parenteral fluid.
Potassium chloride (40 mEq.) should be added
to the sixth liter, and potassium phosphate (40
mEq.) should be added to the seventh liter of 5
per cent glucose solution. If symptoms or signs
of hypopotassemia (weakness, respiratory par-
alysis, and electrocardiographic changes) super-
vene in spite of the aforementioned potassium
therapy, the concentration can be increased to
80 mEq./l.

It is possible to use commerciallv available

solutions to accomplish approximately the same,
results (table 8). One can substitute half-strength
lactated Ringer’s solution to which is added 40
mEq. of potassium phosphate to 1 liter and 40
mEq. of potassium chloride to the other. Butler’s
solution can also be used. Still other solutions
with this approximate composition can be sub-
stituted.

On admission, shock or borderline shock may
be corrected by the rapid infusion of the first 2
liters of fluid, since simple hypovolemia may be
the cause. However, not all patients with shock
will respond, and, particularly, those with pro-
found shock will require a plasma expander, such
as 6 per cent dextran solution or whole blood or
plasma. In some instances, noradrenalin (or
other vasopressor substances ) may be needed to
maintain blood pressure if plasma expanders in
reasonable amount fail to do so.

Potassium should be started about four hours
after starting insulin. In general, potassium
should not be administered unless urine flow is
adequate. However, if respiratory symptoms or
grave electrocardiographic abnormalities occur.

TABLE 8

Volume

Na.

Cl.

Lactate

K.

HPO,

Mg.

Ringer’s lactate

1,000

130

107

28

4

Ringer’s lactate

1,000

130

107

28

4

“Electrolyte No. 2

1,000

57

70

25

45

12.5

6

“Electrolyte No. 2

1,000

57

50

25

45

32.5

6

Glucose 5 % with KC1.

1,000

20

60

40.

5,000

374

354

106

158

85.

12

“Plus 20 mEq. potassium chloride to 1 liter and 20 mEq. potassium phosphate to the other.

FEBRUARY 1958

41

a small amount of potassium (40 mEq.) should
be given. Extremely careful observation is neces-
sary under these circumstances. Some initial
potassium deficit would be an advantage during
the treatment of prolonged anuria, but hvpopo-
tassemia could also aggravate the renal damage
or cause death from arrhythmia or paralysis.

In the presence of congestive heart failure or
alter acute myocardial infarction, the fluid pro-
gram has to be greatly modified. When edema
exists in heart failure, the extra fluid stores will
be called on, and the primary and, often, only
therapy is adequate insulin administration. Since
the electrocardiogram becomes useless to detect
hypopotassemia in many cardiac patients, po-
tassium determinations are needed to decide
whether to administer potassium.

A review of the course of treatment of 25
patients with diabetic acidosis treated at this
hospital from 1952 to 1955 was made to deter-
mine how the general principles mentioned
before were actually put into practice. Some
records showed many defects, whereas others
approached ideal management. There were no
deaths, but onlv 3 patients were actually coma-
tose and the severity in general was not as great
as in many reported series.

The following records the average fluid and
electrolyte therapy of 25 instances of diabetic
acidosis (in 17 patients) during the first twenty-
four hours.

REFERENCES

1. Beaser, S. B.: Diabetes mellitus (medical progress review).
New England J. Med. 255:173, and 223, 1956.

2. Field, J. B., Stetten, DeWitt, Jr.: Observations on causes
and mechanism of insulin resistance during diabetic acidosis.
J. Clin. Investigation. 35:703, 1956.

3. Atchley, D. W., and others: On diabetic acidosis; detailed
study of electrolyte balances following withdrawal and re-
establishment of insulin therapy. J. Clin. Investigation. 12:
297, 1933.

4. Butler, A. M., and others: Metabolic studies in diabetic
coma. Tr. Assoc. Am. Physicians. 60:102, 1947.

5. Nabarro, J. D. N., Spencer, A. G., and Stowers, J. M.:
Metabolic studies in severe diabetic ketosis. Quart. J. Med.
21:225, 1952.

6. Holler, J. W.: Potassium deficiency occurring during treat-
ment of diabetic acidosis. J.A.M.A. 131:1186, 1946.

Water, cc. 5,700

Sodium, niEtj. 525

Potassium, mEq. (20°) 105

Chloride, mEq. 454

Bicarbonate, mEq. (18®) 150

Phosphate, mEq. (7®) 77

“Number of instances where the ion was administered.

Since the figures shown are average, some
patients received inadequate amounts and some
excessive amounts. The extremes were 155 mEq.
of NaCl. in 1 patient to 1,065 mEq. of sodium,
783 mEq. of chloride, and 332 mEq. of bicarbo-
nate in another. Potassium therapy was inade-
quate in many instances. These figures do not
take into account electrolytes and fluid lost in
the urine. Rapid control of hyperglycemia and
ketonemia minimize such losses.

SUMMARY

An attempt has been made to present a form of
therapy for diabetic acidosis which is based on
knowledge of deficits which occur during the
development phase of acidosis. Major emphasis
has been placed on a correct diagnosis, large
doses of insulin given early, treatment of allied
and precipitating conditions, early and repeated
determinations of desired progress of glucose
and ketone levels, and a reasonable approach to
replacement of deficits of fluid and electrolytes
known to exist in diabetic acidosis.

7. Smith K., and Martin, H. E.: Response of diabetic coma to
various insulin dosages. Diabetes 3:287, 1954.

8. Zieve, L., and Hill, E.: Prognosis in moderate or severe
diabetic acidosis. Arch. Int. Med. 92:63, 1953.

9. Zieve, L., and Hill, E.: Comparative importance of severity,
and therapeutic effort in determining outcome of diabetic
acidosis as observed in a representative group of patients. J.
Lab. & Clin. Med. 43:107, 1954.

10. Harwood, R.: Diabetic acidosis. New England J. Med. 245:
1, 1951.

11. Joslin, E. P., Root, H. F.. White, P., and Marble, A.: The
Treatment of Diabetes Mellitus, ed. 9. Philadelphia: Lea &
Febiger, 1952, p. 371-373.

12. Duncan, G. G.: Diabetic coma — therapeutic problem. Ann.

Int. Med. 37:1188, 1952.

42

THE JOURNAL-LANCET

Trauma and Thrombophlebitis

JOHN FARR, M.D., F.R.C.S.(C.) (Edin.)
Winnipeg, Manitoba

Thrombophlebitis in the lower extremities
is sometimes a late complication of severe
injury elsewhere than in the legs. It may de-
velop days or weeks after such an injury. After
a fracture of the spine or the femur, patients are
usually at rest in bed and, in addition, have suf-
fered trauma to their soft tissues. The mechan-
ism of thrombosis in such patients is thus very
similar to that of thrombophlebitis occurring
after surgical procedures, and the later effects
of the thrombophlebitis are usually recognized
and treated because the acute phase has been
recognized.

There is another group of cases of great im-
portance, namely, direct injuries to the leg,
which may or may not result in fracture. Re-
cause the swelling may be thought to be due
to simple trauma or because the limb is hidden
in a cast, the resultant thrombophlebitis is fre-
quently not recognized. The high incidence of
this condition is evidently not appreciated and,
therefore, it is frequently not treated early or
with the vigorous postphlebitic management that
such a case should have. Reviewing the litera-
ture for the last ten years fails to reveal one
article on thrombophlebitis directly related to
trauma. The absence of literature on the subject
indicates either a lack of awareness or indiffer-
ence to this condition. Recause of the consid-
erable disability that results when the postphle-
bitic changes have progressed to a stage where
the patient is unable to work, despite his recov-
ery from the original Tin jury, careful evaluation
and recognition of this condition is important.
Dr. D. J. Fraser has kindly provided me with
some data on such patients taken from the Work-
men's Compensation Board’s files here. They are
not statistical samplings but illustrate how im-
portant the disability in certain cases may be.
A few illustrative examples follow.

A 28-year-old male had a fractured calcaneus and
ischium in 1952. He did not work for approximately
a year. In May 1956, four years later, lie was receiving
a 5 per cent disability for thrombophlebitis. There was
a 4-cm. difference in the circumference of the leg.

A 39-year-old male fractured his tibia and femur in

john farr is a lecturer in surgery at the University
of Manitoba and a surgeon at the Winnipeg Clinic.

1943. This patient suffered mostly from postphlebitic
edema, and permanent disability was 30 per cent. He
would have received 40 per cent if he had had an am-
putation.

A 50-year-old male, who suffered bruises and swelling
of both legs and thighs in December 1946, was dis-
charged from the hospital in February 1947 and returned
to work in April 1947. However, he had a continuing
disability, and, in 1949, a bilateral sympathectomy was
performed. In April 1956, he was receiving a 10 per
cent disability pension for the effects of old thrombo-
phlebitis.

A 48-year-old male, who suffered a fractured meta-
tarsal in July 1953 and had pronounced swelling after
removal of the cast, was admitted to the hospital for
anticoagulants. In 1956, his pension was reduced from
25 to 15 per cent.

A 54-year-old male, who fractured his left tibia and
fibula in 1953, is now receiving a permanent disability
of 25 per cent for bilateral phlebitis, 5 per cent of which
is related to a limited flexion of the knee.

A 32-year-old male twisted his right ankle while shov-
eling coal and returned to work in a month. He was
thought to have cellulitis and eventually had his veins
ligated. This patient works from time to time, but ulcers
recur.

Many of these patients with lower leg frac-
tures or contusions are disabled because of ven-
ous insufficiency long after the orthopedic or
traumatic surgeon has dismissed them as healed.
In some cases, it may be thought that the patient
is exaggerating his disability. Patients should
not be pampered, but any patient with a limb
that is swollen 2 to 4 cm. more than the other
leg should be treated as if he were suffering from
the effects of deep venous insufficiency, because
it is impossible to tell whether the edema and
cyanosis are due merely to loss of vascular tone
and increased permeability of the vessels or
whether the patient actually had a deep throm-
bophlebitis at the time of the original injury.
Whatever the cause of the edema, if appropriate
measures regarding management are not insti-
tuted, a serious disability will probably result.
These patients deserve treatment to reduce the
edema, because, if the edema is allowed to per-
sist, it eventually becomes irreversible. The plas-
ma outside the blood vessels tends to fibrose, and
this fibrosis leads to some degree of anoxia of
the skin, which, in turn, leads to further fibrosis
and scarring of the lymphatics. Ultimately, the
skin changes appear with the typical stigmata of
chronic deep venous insufficiency. I am not sug-

FEBRUARY 1958

43

gesting that patients with soft tissue injuries and
fractures of the lower leg should receive anti-
coagulants, because such treatment might cause
certain complications. However, I feel that when
plaster casts or other methods of immobilization
or support are removed from these patients, it
is of great importance to direct careful attention
toward the management of the edema of the
limb because, in some cases, deep thrombophle-
bitis will have occurred.

The surgical treatment of this form of throm-
bophlebitis includes various procedures, depend-
ing upon the stage of the thrombophlebitis and
the nature of its complications. These measures
include femoral or popliteal vein ligation, sym-
pathectomy, and excision with skin graft.

My experience leads me to believe that the
procedure of choice must be carefully selected
on an individual basis in order to secure the most
beneficial result.

Irrespective of this, however, by far the most
important management is that outlined in the
“New Way of Life,” described by Luke1 in 1950.
This important communication stresses the me-
chanical measures necessary to prevent develop-
ment of edema and avoid the consequent irre-
versible changes that will occur.

The patient is given typed instructions regard-
ing the importance of intermittent high eleva-
tion, constant elastic support on the limbs when
in a dependent position, and is warned of the
dangers of strong soaps and actinic (sunburn)
trauma. A genuine effort must be made to have
the patient understand his or her condition. The
only way dependent edema can be kept at a
minimum is by intermittent elevation of the legs
and properly applied elastic bandages or hose.
The importance of these measures must be em-
phasized and re-emphasized!

It is my feeling from a practical point of view
that it does not really matter whether the cause
of chronic venous insufficiency is an actual
thrombophlebitis or merely a temporary venous
insufficiency occasioned by prolonged immobil-
ity and lack of muscular action. The effect is the
same in both, although, of course, it is more
severe in the former than the latter. A delay in
returning to work and a recurring or permanent
disability may be avoided if considerable atten-
tion is paid to the care and management of pa-
tients with edematous extremities which develop
after injuries.

THROMBOPHLEBITIS IN UPPER EXTREMITIES

Venous thrombosis in the arm is of considerable
interest. I do not refer to thrombosis induced
by chemical irritation, such as occurs after in-

travenous injection of Diodrast or anesthetic
agents, or thrombosis induced by stasis in the
superior vena cava syndrome. However, I would
like to draw attention to a type of venous throm-
bosis described as “Ideopathic Thrombosis of the
Axillary Vein.” French authors have a more de-
scriptive term, “Thrombophlebite Axillaire Par
Effort,” which serves to distinguish it from
thrombosis or thrombophlebitis caused by direct
external injury. Rudolph Matas,2 renewing at-
tention to the condition in 1934, called it “Pri-
mary Thrombosis of the Axillary Vein Caused
by Strain." Such a term is, perhaps, clumsy but
does emphasize the most important factor in its
etiology. The condition is of more than passing
interest to a surgeon dealing with insurance or
workmen’s compensation cases.

Patients suffering from this type of thrombosis
do not usually give a history of injury or acci-
dent but, if interrogated, will recall an incident
of excessive muscular effort. The history of ex-
cessive muscular effort does not qualify a patient
for workmen’s compensation in Manitoba, as,
under the terms of the Compensation Act, a pa-
tient is required to be injured by “accident” be-
fore the Compensation Board will accept respon-
sibility for the injury. Accident may mean many
things to many people, but I think the definition
mentioned by Matas is a useful one, namely,
“an unforeseen event directly or indirectly atrib-
utable to the sudden, violent action of external
causes.” Some of the causes of this type of throm-
bosis mentioned in the literature are hoisting
heavy bales, heavy work with a hammer, lifting
objects onto a high shelf, vigorous rowing, crack-
ing a whip, and so forth. It is thought that the
mechanism of injury is as follows. During ex-
treme physical effort there is a coincidental ex-
treme respiratory effort which causes the axil-
lary vein to become distended so that it is more
likely to be injured. Then, for instance, at the
end of a rowing stroke, the clavicle is pulled
downwards and backwards, and the anterior sca-
lene muscle and the costocoraeoid ligament pro-
duce pressure on the vein with consequent trau-
ma, perhaps even causing a slight tear in the in-
tima. It should be mentioned that, despite a his-
tory of strain, axillary thrombosis is a complex
syndrome of polyvalent causation in which in-
direct trauma of the axillary vein and its imme-
diate environment play the leading role. To show
that there are other factors in the causation of
the thrombosis besides strain, I should mention
the case of one patient who required readmission
two davs after discharge from treatment for axil-
lary vein thrombosis. Her admission was neces-
sitated by a moderately severe iliofemoral throm-

44

THE JOURNAL-LANCET

bophlebitis. This, of course, suggested that some
increase in the clotting mechanism was present.

The condition is characterized by signs and
symptoms out of all proportion to the extent and
degree of the trauma. The arm swells and be-
comes livid or even cyanotic. The edema can
be firm or doughy. The veins over the chest wall
may or may not be distended. Usually, the pa-
tients are young and muscular and employed in
heavy labor. As might be expected, the sex in-
cidence in the male and female is 4:1.

In my own cases, the diagnosis of axillary vein
thrombosis has always been obvious and a veno-
gram did not seem to be necessary, especially in
view of the fact that injection of an opaque sub-
stance can itself cause venous thrombosis.

It should be mentioned that a roentgenogram
of the thoracic inlet and mediastinum is obliga-
tory to exclude lesions causing obstruction of
the subclavian or innominate veins.

Most patients respond very well to conserva-
tive measures: namely, elevation, heat, and anal-
gesics. The use of anticoagulants no doubt di-
minishes extension of the thrombosis, and, if

REFERENCES

1. Luke, J. C.: Evaluation of deep veins following previous

thrombophlebitis. Arch. Surg. 61:787, 1950.

facilities exist for their use, such therapy is ad-
visable. The majority of patients are relieved of
their symptoms in seven to fourteen days, and
the residua are minimal with none of the trouble-
some late complications occurring with venous
insufficiency in the lower extremity.

If symptoms persist, exploration of the appro-
priate supraclavicular fossa should be done. In
one such case requiring operation, I found an
elongated transverse process of C7 vertebra with
a fibrous band extending from its tip to the first
rib. Section of this resulted in cure.

No doubt some would advocate opening the
vein and removing the thrombus, but this pro-
cedure carries an unnecessary risk of air em-
bolism, recurring thrombosis, or embolism, and,
in my opinion, it should not be done.

Finally, it should be generally recognized, as
Matas stated, that there is a medicolegal differ-
ence between primary spontaneous thrombosis
caused by muscular strain (indirect injury) and
so-called spontaneous thrombosis, which occurs
without history of accident, antecedent injury,
or continued occupational strain.

2. Matas, R.: Primary thrombosis of axillary vein. Am. J.

Surg. 24:642, 1934.'

Exsanguinating hemorrhage from alimentary tract diverticula is most apt
to occur with extensive involvement of the colon. Although the exact mech-
anism of such hemorrhage remains obscure, infection is not incriminated.
Local trauma producing ulceration is the most important etiologic factor.

Because of the infrequency of the condition, treatment has not been stand-
ardized. When bleeding is slight, and often when massive, rest, sedation, bland
diet, and blood transfusions comprise satisfactory management. When bleeding
continues and the source is localized, an elective resection of the diseased bowel
is done. With massive bleeding from the entire colon, localization of the precise
bleeding point is usually impossible and the necessary total or subtotal colec-
tomy in this situation is a formidable procedure.

Simple diversion of the fecal stream controlled massive hemorrhage from
diverticulosis in 2 patients. Since bleeding from the right colon seldom occurs,
a transverse colostomy usually suffices. Definitive management can then be
settled on an individual basis.

Charles D. Knight, M.D., Confederate Memorial Medical Center, Shreveport, Louisiana. Sur-
gery 42:853-861, 1957.

FEBRUARY 1958

45

Pilonidal Disease

KARL ZIMMERMAN, M.D.
Pittsburgh, Pennsylvania

The following method of treating pilonidal
disease has been published twice before1,2
and has been explained to several medical groups
and societies. Because of the growing interest
and the number of requests received recently,
this simple method of treatment is presented
again with a series of more than 1,000 cases to
substantiate its efficiency.

Pilonidal disease is characterized by the pres-
ence of midline sinus tracts and associated cystic-
cavities usually found in the tissue over the
lower sacrum and coccyx. Similar sinuses and
cysts have been reported as occurring anterior
to the anus, on the upper back, in the navel, and
between the fingers of barbers. The condition
is more common in hirsute white males. About
half these cysts and sinuses contain hair. Sinuses
and dimples in the sacrococcygeal area are seen
frequently in children, but infected cysts are not.
The condition usually becomes symptomatic be-
tween the ages of 18 and 30. These are the same
years in which hydradenitis suppurativa is prev-
alent.

The cause of pilonidal disease is not yet
known. The sinus tracts may be congenital, but
there is no conclusive proof that they arise from
epithelial arrests, remnants of the notochord,
neurenteric canal, or preen glands as has been
suggested by various authors. There is much
reason to believe that the cysts, in contradistinc-
tion to the sinuses, are acquired and that they
are caused when hair and detritus from the skin
penetrate the sinus tracts and, along with bac-
teria, cause irritation and abscess formation.

Microscopically, pilonidal sinuses are found to
be lined with stratified squamous epithelium. A
cyst may be partially lined with stratified epi-
thelium, but most of the cavity is lined with in-
flammatory tissue. Occasionally, hair follicles are
found in a cyst cavity, but never are enough fol-
licles seen to explain the mats of hair sometimes
removed from pilonidal cysts. The hair in the

karl zimmerman is assistant professor of surgery
and head of the Section of Proctologi/ at the Univer-
sity of Pittsburgh School of Medicine.

Presented at the New Orleans Graduate Medical
Assembly , March 11, 1957.

cysts is not attached to follicles and is easily
lifted from the cavity. The amount and length
of the hair is often sufficiently abundant to refute
the theory that the hair in pilonidal cysts breaks
off the back and lodges in the sinuses.

The symptoms of pilonidal disease are the
same as those for localized subcutaneous infec-
tions anywhere in the body.

The number of operations described for the
cure of this condition is fantastic. During World
War II, a game was played in the Air Force in
which a surgeon “dreamed up” a method of
operating on pilonidal cysts. The literature was
then searched, and usually a description of the
“dream method” could be found. It was during
World War II that the Air Force, as part of the
routine physical examination for its members,
looked specifically for pilonidal disease. As a
consequence of this requirement, as many as
60 cases of pilonidal disease were present in
some station hospitals at one time. This wealth
of material provided an excellent opportunity
for the study of this disorder. It was in such
a hospital that the method of treatment pre-
sented here was developed.

After all reasonable methods of closure had
been tried and proved unsatisfactory because of
the recurrence rate, it was decided to try to
find a better open method than a wide block
dissection, which left a wound that required
months to heal.

The first patients operated upon after this de-
cision was made had their cysts and sinus tracts
unroofed. Sections were then taken from vari-
ous parts of the sinuses and evst cavities, and
drawings were made of the involved areas indi-
cating the location of removed sections. These
sections were examined microscopicallv, and the
findings were considered in regard to the loca-
tion from which they had been removed. It was
concluded that the walls of pilonidal sinuses are
covered by stratified squamous epithelium. This
stratified squamous epithelium extends for vary-
ing distances into the cyst cavities but never
completely lines them. Whether a cyst was ever
completely lined with stratified epithelium,
which was then partially destroyed by infec-
tion, was considered but rejected as unsubstan-

46

THE JOURNAL-LANCET

Fig. 1«. Preoperative picture of 2 congenital openings of pilonidal sinuses in the midline and an acquired opening
above and to the left. (bK Probe in congenital sinus, (c). Tract slit open showing hair in sinus and cyst cavity.
(d). Lining of sinus and cyst after being wiped free of hair and detritus. (eh Cotton saturated with 1:5,000 epi-
nephrine solution in wound. (f>. First postoperative day. (g). Eighth postoperative day. (hh Thirteenth postopera-
tive day. (V. Twenty-second postoperative day.

FEBRUARY 1058

47

tiated. It was more reasonable to assume that
the pilonidal cyst was an abscess cavity caused
by infection entering the lower end of a sinus
tract and extending through its sweat glands or
hair follicles into the surrounding tissue.

Whatever might have been the underlying
cause of pilonidal cysts, they healed rapidly and
with practically no recurrence when nothing was
done but a simple unroofing and cleaning pro-
cedure. Also, healing was much more rapid than
when a wide block dissection was made. In
view of the success of this procedure, more and
more of the roof of the cyst was allowed to
remain in place until the present procedure
evolved.

The method now used is simple. A probe is
passed into the sinus tract or tracts and cavities,
and the overlying tissue is separated with the
scalpel or scissors. The lining so exposed is
wiped clean with a piece of dry gauze. This lin-
ing is then examined and probed for side tracts
or cavities. If found, they are slit open the same
as the primary one. Palpating the tissue adjacent
to the tracts may reveal induration, which indi-
cates the presence of a side tract or cavity. This
procedure helps the operator find all the in-
volved areas. No tissue is removed unless the
cavity or tract is deep and there is chance of
the skin healing over before the wound is filled
with granulations. The edges of these wounds
are beveled in order to “saucerize” them and
prevent bridging. No ties are used on bleeders
if they can be avoided. The less foreign material
in the wound, the better it will heal. Bleeders
are pinched with hemostats and twisted. A piece
of gauze saturated with 1:5,000 epinephrine
solution or on a piece of Gelfoam or Oxycel is
placed in the wound, and a pressure dressing is

applied. Occasionally, a persistent bleeder is
found that requires control by electrical coagu-
lation or even a tie, but this is avoided if pos-
sible.

Six to eight hours after operation, wet dress-
ings of saline or boric acid solution are placed
over the pressure dressing which was applied at
operation. The next day, the pressure dressing
is removed, but the wet dressings are continued.
If bleeding has ceased, the patient is discharged
from the hospital on the second postoperative
day. The wet dressings are continued at home.

Twice each week following discharge from the
hospital, the wound is examined and dressed in
the office. At each visit, the entire healing area
is observed for signs of delayed healing or open-
ings to tracts that have been missed. If a tract
is found, it is unroofed under local procaine
anesthesia. Areas in which granulations are not
healthy are examined for the presence of a hair
or other foreign material, which is removed if
found.

It usually takes about ten days for all the
granulations to become clean and healthy. The
wet dressings are stopped at this time, and the
patient is advised to place gauze covered with
Furacin on the wound and to change the dress-
ings three or four times a day. A sanitary belt
and perineal pad are used to hold the wet dress-
ings in place and also may be used to retain the
Furacin dressings. Wet dressings are far more
beneficial than any ointment or cream-based
applications for the first ten days. After the
wounds are clean, creams in water-miscible bases
are most effective. Ointments with a petrolatum
base delay healing even though they do contain
antibiotics or antiseptics.

The known recurrence rate in these cases is

c

Fig. 2. Exten-
sive scar fifty
days postopera-
tively. Epitheli-
zation had been
complete nine
days.

Fig. 3. Scar of
pilonidal wound
seven years aft-
er operation.

48

THE JOURNAL-LANCET

less than 2 per cent, and recurrences are treated
in the same manner as the original infection.

Since this method is contrary to the accepted
teaching of the past, which states that all the
lining of a pilonidal cyst or sinus must be re-
moved in order to effect a cure, photographs of
the operation and the healing wounds were
taken as evidence of its validity. Some of these
photographs are presented to show that the
lining of a pilonidal cyst or sinus need not be
removed in order to cure the condition (figure
lrt through i ). Two pictures (figures 2 and 3)
of completely healed extensive scars are pre-
sented to show that large as well as small
pilonidal cysts may be cured by this method.
Figure 2 shows a scar seven weeks postopera-
tively, and figure 3 shows another scar seven
years after the operation.

The average time required for complete epi-
thelization in all cases is twenty-three days. Al-

REFERENCES

1. Zimmerman, K.: Pilonidal disease — an open method of

operation. Tr. Am. Proc. Soc. p. 515, 1946.

though it has been impossible to obtain definite
detailed statistics on all the cases that have been
treated by this method during and since World
War II, the number is well over 1,000 and the
known recurrence rate is less than 2 per cent.

This method can be used in the office for small
cysts and sinuses, but caution is urged because
the extent of the procedure is not always known
until the tract has been opened. The surgeon
may find that a more extensive operation is re-
quired than he wishes to perform in the office.

SUMMARY

A well-tested and simple method of successfully
treating pilonidal disease is again presented with
additional cases fortifying the gratifying results
previously reported.

Since this method is contrary to long-accepted
beliefs and teaching, photographs are shown to
verify the facts presented.

2. Zimmerman, K.: Surgical treatment of pilonidal disease.

J. Internat. Coll. Surgeons 24:104, 1955.

Needle biopsy of the kidney is a valuable procedure in the detection of or-
ganic renal disease, but it should not be performed unless the information to
be gained is of definite worth. Renal biopsy may be used to differentiate mul-
tiple renal diseases in the nephrotic syndrome and to aid in the diagnosis of
acute renal insufficiency and diffuse renal and vascular diseases. Often, the
stage of the disease process is revealed, and subsequent specific therapy im-
proves the prognosis.

Contraindications to renal biopsy include bleeding abnormalities; fulminat-
ing uremia; unilateral kidney; total anuria, unless a catheter is inserted and the
pelvis is irrigated; renal abscess or tuberculosis; perinephritis; and malignant
hypertension.

Biopsy, using local anesthesia and a Vim-Silverman needle, is performed
with the patient in the prone position. Attempts to obtain a successful biopsy
should be limited to 3.

Satisfactory renal tissue was obtained at first attempt in 137, or 91 per
cent, of 150 patients. Subsequent biopsies were satisfactory in 10 of the re-
maining 13 subjects. Glomeruli averaged 16 per section.

George E. Schreiner, M.D., and Leonard B. Berman, M.D., Georgetown University Hospital,
Washington, D.C. South. M. J. 50:733-739, 1957.

FEBRUARY 1958

49

The Clinical Significance of Hoarseness
and Related Voice Disorders

HANS VON LEDEN, M.D.
Chicago, Illinois

What is the chief function of the human
larynx? It is the production of voice, all
of us would agree, even though we remember
the importance of this organ as guardian of the
lower respiratory passages. This instinctive asso-
ciation between the human larynx and voice is
not surprising, considering the unique position
of voice and speech as the principal mediums of
communication among men. It is attested by the
translation of the Greek word “larynx” into the
English vernacular “voice box.” While the larynx
plays a prominent role in many other functions,
such as respiration, expectoration, deglutition,
and fixation, these functions are duplicated in
most vertebrates; but only man can “voice” his
thoughts.

This distinctive human property, which ex-
cludes the use of laboratory animals for inves-
tigations, has retarded our understanding of the
many complex phenomena which add up to the
production of voice. Recent experiments, includ-
ing the adaptation of ultra high speed cinema-
tography, have produced a better understanding
of the numerous physiologic derangements re-
sulting in hoarseness and related voice disorders.

A few fundamental principles of laryngeal
physiology will assist in a better understanding
of these phenomena. In normal voice produc-
tion, the lungs act as bellows which force air
under pressure against the lower surfaces of the
closed vocal cords, pushing them apart. Some of
the air escapes through this opening until the vo-
cal cords reapproximate— the result of their own
elasticity and the reduced lateral pressure in the
larynx. As soon as the subglottic pressure rises
sufficiently to overcome the resistance of the
vocal cords, the same cycle is repeated again
and again. These alternations create puffs of
air, which are perceived by the listener as

hans von eeden is assistant professor of otolaryn-
gology at Northwestern University Medical School,
medical director of William and Harriet Gould Foun-
dation, and attending staff physician at Chicago
Wesley Memorial Hospital, St. Fra
(Evanston), and Cook County Hog

sound or, modified by the organs of the upper
respiratory tract, as speech. Tlie shorter the in-
tervals between successive cycles, the greater
the frequency of vibrations and the higher the
pitch of the sound produced.

The process of voice production, therefore, in-
volves (1) the larynx as the primary source of
tone, ( 2 ) the chest as the source of the motive
power, (3) the resonance chambers of the head
and the pharynx, and (4) the related muscles
and motor nerves. Any variation may and often
does result in a change of sound, particularly if
the disturbance affects some of the vital muscles
in the larynx itself or their nerve supply. The
great number and diversity of the intrinsic laryn-
geal muscles attest to the complexity and deli-
cacy of the adjustments necessary for normal
voice production, and the length of the recur-
rent laryngeal nerve renders this main motor
nerve of the larynx particularly vulnerable.

Any modification of normal laryngeal function
results in one of three characteristic changes in
sound: A change in pitch, volume, or quality.
A change in pitch depends upon the mass and
tension of the vocal cords, not on their length,
as erroneously assumed for many years. The
volume varies with the pressure of the released
pulsations, that is, relative changes in the vibra-
tory cycle. Incomplete interruption of the air
flow, the creation of turbulences, or a change in
the vibratory pattern alter the quality of the
voice and give rise to hoarseness. Loosely speak-
ing, any change in the natural voice of an indi-
vidual is often referred to as “hoarseness."

From this brief description, it is quite appar-
ent that hoarseness is not a disease in itself but
rather a symptom of disease in the larvnx or
along the course of the laryngeal motor nerve.
Thus, hoarseness is the cardinal symptom of
laryngeal involvement. It may result from faultv
approximation of the cords, inadequate firmness
of the cordal margins, or even slight changes in
the vibratory pattern. It is often the first and
only sig'fial of serious local or systemic disease.
Several months ago, a patient consulted me
a historv of progressive hoarseness. As she

50

THE JOURNAL-LANC1

walked into the office, a slight limp was ob-
served. When she was asked to grasp her tongue
during the course of the examination, a wasting
of the thenar eminence became evident. Indirect
laryngoscopy showed a uniform weakness of
both cords, as seen in cases of muscular atrophy.
Somewhat rashly, I diagnosed amyotrophic lat-
eral sclerosis and referred the patient to a neu-
rologist who confirmed this diagnosis. On an-
other recent occasion, I was asked to see a pa-
tient with hoarseness of recent onset. Indirect
laryngoscopy revealed a weakness of one vocal
cord, but a neurologic examination proved en-
tirely negative. One week later, the unilateral
paralysis was complete, and I was able to pal-
pate a small, hard tumor at the thoracic inlet,
largely obscured by the clavicle. Roentgeno-
grams revealed an earlv malignancy of the ali-
mentary tract. These two patients are representa-
tive of the many unusual cases in individuals
who seek medical attention primarily because
they or their associates have noted the symp-
tom of hoarseness. Occasionally, the differen-
tial diagnosis may tax the ingenuity of the at-
tending physician, since hoarseness may be a
significant complaint in over 100 different med-
ical and surgical conditions.

The most common benign cause of hoarseness,
laryngitis, has been experienced by almost every
| adult at some time, and this familiarity “breeds
contempt.” As a result, many cases of laryngeal
disease remain undiagnosed for weeks or months,
while the opportunity for their successful eradi-
cation diminishes from day to day. Laryngeal
\ cancer is not uncommon and, in its early stages,
affords an excellent prognosis. Under these cir-
cumstances, who would quarrel with the old
dictum that all patients with a hoarseness of
more than three weeks’ duration deserve the
benefit of a laryngeal examination?

Such an examination must not be limited to
a cursory view into the mouth or, perhaps, a
brief glance into the throat. An adequate ex-
i animation for hoarseness includes careful inspec-
tion of the nose, paranasal sinuses, the mouth,
the nasopharynx and throat; a detailed study
of the hypopharynx and larynx; palpation of the
tongue, floor of the mouth, and the entire neck;
and such additional examinations and laboratory
studies as each individual case may warrant. If
indirect laryngoscopy with local anesthesia does
not permit complete visualization of the larynx,
a direct larvngoscopic examination under top-
ical,' intravenous, or inhalation anesthesia is in-
dicated. All suspicious lesions should be removed
for biopsy, for every doubtful case must be con-
sidered malignant until proved otherwise.

In the past, many physicians and patients have
been distressed by the difficulty experienced in
evaluating certain mild cases of hoarseness or
very early laryngeal lesions. The clinician has
been handicapped by the inherent limitations
of the human eye in distinguishing the rapid
motions of the vocal cords, which vibrate at a
rate of 200 to 400 cycles a second. Furthermore,
in direct larvngoscopic examinations, the distor-
tion of the normal anatomy by the introduction
of the rigid instrument is often sufficient to ob-
scure early changes in laryngeal function. Re-
cent comparative cinematographic studies by
Professor Paul Moore and the author, in normal
and ultra slow motion, during which laryngeal
vibrations are magnified 250 times, have demon-
strated the value of such studies in the diagnosis
of early functional abnormalities. With the per-
fection of the electronic synchron-stroboscope by
Timcke and by Van den Rerg, even minimal
lesions of the vocal cords can be discovered and
accurately interp reted. These recent additions
to our diagnostic armamentarium should encour-
age the successful investigation and treatment
of many baffling cases.

While hoarseness may be caused by an almost
infinite variety of organic or functional disor-
ders. this discussion will be limited to the more
common clinical entities.

INTRINSIC LESIONS OF THE LARYNGEAL
TISSUES

Inflammations. Inflammatory lesions comprise
by far the major portion of all laryngeal disor-
ders. Acute laryngitis, usually the result of an
upper respiratory infection or excessive vocal
use. is a self-limiting disease which responds
readily to supportive measures, minimal use of
the voice, and the avoidance of such irritants
as smoke, alcohol, and hot food. The same ap-
plies to the specific laryngitis accompanying con-
tagious or infectious diseases. Fortunately, with
the advent of antibiotic therapy, diphtherial lar-
yngitis, the dread scourge of past generations,
has practically disappeared. I have seen only
one case of this tvpe at the Cook Countv Hos-
pital during the past ten years. Early tracheoto-
my or intubation remains the treatment of choice
in these isolated cases. The same advice holds
true in children with acute laryngotraeheobron-
ehitis, where hoarseness acts as a warning signal
of beginning laryngeal edema.

Chronic laryngitis may be caused by an infec-
tion of the upper respiratory tract, particularly
a chronic sinusitis, or by a variety of irritants,
such as vocal abuse, excessive smoking, or in-
halation of dust or fumes. While the pathology

FEBRUARY 1958

51

may vary, a reversal ot the chronic changes may
best be accomplished by elimination of the etio-
logic factor, vocal temperance, and the absten-
tion from local irritants. Gargles and troches
have only psychologic value and may lure the
patient into a false sense of security. For em-
phasis, it must be repeated that a diagnosis of
chronic laryngitis should never be established
until a thorough examination of the larynx has
ruled out serious disease.

Laryngeal neoplasms. Laryngeal tumors fol-
low inflammations in their incidence but far sur-
pass them in importance. Benign tumors include
polyps, fibromata, and cysts, which may readily
be removed through the laryngoscope, and the
juvenile papillomata, which often recur after ex-
cision. Vocal nodules or “singers’ nodes” are
small tumors commonly seen in entertainers or
professional people. Frequently bilateral and
located at the junction of the anterior and middle
thirds of the vocal cords, they are the result of
persistent vocal overuse. In their early stages,
they are edematous and respond well to voice
rest and voice therapy. When fibrosis has taken
place, surgical removal becomes necessary.

Malignant tumors of the larynx are relatively
common, comprising over 2 per cent of all malig-
nancies. They strike principally in the fifth or
sixth decades of life, and 10 times as often in
men as in women. It cannot be stressed too
strongly that hoarseness is usually the only mani-
festation of early laryngeal carcinoma. Pain,
bleeding, dysphagia, dyspnea, stridor, and other
symptoms do not occur until late in the disease.
If confined to the vocal cords, carcinoma of the
larynx shows an excellent prognosis. In small
lesions, a cure may be predicted in 95 to 98 per
cent, while the cure rate is still about 80 per cent
when an entire cord is involved. The voice can
be expected to be good in these patients follow-
ing surgery. In expert hands, radiation may also
produce verv good results in early intrinsic laryn-
geal malignancies.

If the tumor has spread beyond the cords,
however, the prognosis is less favorable, and re-
moval of the lesion usually requires a laryngec-
tomy, with or without radical neck dissection,
by removing the organ of voice production, the
patient is doomed to a permanent tracheostomy.
In such cases, a new system of speech can usu-
ally be developed by utilizing the sphincteric
muscles at the upper end of the esophagus. This
striking contrast in the mortality and functional
end results of incipient or advanced laryngeal
carcinoma emphasizes more than many words
the vital necessity for early diagnosis of all sus-
picious lesions of the larynx.

Allergies. Angioneurotic edema or other aller-
gic conditions may involve the larynx and give
rise to hoarseness and rapidly progressive ob-
struction. An emergency tracheotomy should be
considered in acute cases to provide an airway
until medical treatment can reverse the larvn-
gea] manifestations.

Injuries. Traumatic lesions of the larynx may
occur as the result of external injuries with frac-
ture of the larynx, vocal abuse with cord hemor-
rhage, and gunshot wounds. Perhaps the most
common cause of hoarseness in this category is
the so-called “contact ulcer,” resulting from trau-
matic vocal abuse. In this condition, a super-
ficial ulceration develops on the medial surface
of the vocal process of the arytenoid cartilage,
which is exposed to constant hammering from
its mate during the vibratory cycle. Since these
ulcers are apt to recur, such patients deserve a
thorough analysis of their vocal habits, followed
by voice rest and indicated voice therapy. Slow
motion cinematographic or stroboscopic studies
often provide important information in these
cases, while, in my opinion, surgical intervention
is strictly contraindicated.

Persistent overexertion of the voice may also
result in weakness of the laryngeal muscles, with
associated hoarseness. This so-called myasthenia
laryngis is characterized by faulty or inadequate
approximation of the vocal cords on prolonged
stimulation. It is not related to myasthenia gravis
or any other systemic disease. Vocal temperance
and voice therapy are effective countermeasures.

DISTURBANCES IN INNERVATION OF LARYNGEAL
MUSCLES

Disturbances in the innervation of the laryngeal
muscles may be of central or peripheral origin.
In all cases, the treatment is that of the under-
lying disease, although voice therapy during con-
valescence may be helpful in improving the
functional end result.

Disturbances of central origin. Central lesions
include bulbar paralysis, which may be associ-
ated with numerous diseases of the central nerv-
ous system, multiple sclerosis, and tetanus. In
these diseases, laryngeal involvement is com-
monly bilateral, consisting of weakness or pa-
ralysis of both vocal cords, with varying degrees
of hoarseness and dyspnea. Tracheotomy is often
necessary to maintain an adequate airway and
to relieve the secretory obstruction of the lower
respiratory passages.

Disturbances of peripheral origin. Impulses to
the laryngeal muscles are carried by the vagus
and recurrent laryngeal nerves — a long and ex-
posed route. Thus, peripheral involvement of

52

TIIE JOURNAL-LANCET

the laryngeal nerve supply may stem from such
widely different sources as pressure by a tumor
in the neck or mediastinum, cardiac hypertrophy,
an enlarged thyroid, or an aortic aneurysm. In-
jury of the recurrent laryngeal nerve, on the
other hand, is usually the result of extensive
thyroid surgery. While the degree of laryngeal
paralysis varies from case to case, it is always
unilateral except in rare instances of bilateral
recurrent nerve injury during thyroid surgery.
In patients with persistent unilateral vocal cord
paralysis, the resulting hoarseness usually im-
proves over a period of time as the uninvolved
cord assumes the extra burden. Thus, complete
functional compensation may take place as the
result of effective adjustment to the altered
physiologic status.

Peripheral neuritis of the recurrent laryngeal
nerve may occur as a complication of influenza
or other virus diseases or in alcohol poisoning.
In these cases, the resulting paralysis and hoarse-
ness may be permanent, but it is often tempo-
rary, with normal function completely restored.

LARYNGEAL MANIFESTATIONS OF SYSTEMIC
DISEASE

Laryngeal manifestations of systemic disease are
far more frequent than is generally assumed.
Mild forms of hoarseness are often the result of
endocrine disorders, particularly during altered
thyroid metabolism. Muscular dystrophies may
affect the intrinsic muscles of the larynx, with
a resultant weakness in activity and functional
results. In many of these cases, slow motion
studies by svnchron-stroboscopy or ultra high-
speed photography are necessary to detect the
slight functional changes.

Tuberculosis of the larynx is rarely, if ever,
primary. With the decrease in active pulmonary
lesions, laryngeal tuberculosis is seen less and
less frequently. Hoarseness is commonly associ-
ated with pain in laryngeal tuberculosis, but for-
tunately streptomycin provides a specific rem-

edy. In this country, syphilis of the larynx has
become extremely rare.

VOCAL CHANGES WITHOUT DEMONSTRABLE
PATHOLOGY

Emotional disturbances or psychic trauma are
frequently responsible for psychosomatic hoarse-
ness or even aphonia. As opposed to organic dis-
orders, such patients often produce clear sounds
when encouraged to sing or hum individual
vowels or when their attention is channeled in
other directions. Psychosomatic aphonias may
be readily differentiated from organic paralyses
by observing the normal approximation of the
vocal cords while the patient coughs or clears
his throat. The peculiar history of these cases and
the associated psychologic manifestations usually
lead to the correct diagnosis, but the treatment
may prove unexpectedly difficult and often re-
quires prolonged psychiatric supervision.

SUMMARY

This discussion of hoarseness and related voice
disorders points to the following conclusions
concerning their clinical significance:

1. Hoarseness is the cardinal symptom of la-
ryngeal disease.

2. Hoarseness of more than three weeks’ du-
ration must be considered serious unless proved
otherwise.

3. Patients with persistent hoarseness deserve
a thorough laryngeal examination.

4. While hoarseness occurs in many different
systemic diseases, carcinoma of the larynx may
also occur in the presence of other diseases.

5. Earlv diagnosis and treatment of intrinsic
laryngeal malignancies produce excellent cura-
tive and functional results.

6. Newer additions to the diagnostic arma-
mentarium of the laryngologist permit a better
evaluation of early laryngeal lesions.

7. In benign lesions of the larynx, voice ther-
apy is often a useful adjuvant to indicated med-
ical or surgical treatment.

FEBRUARY 1958

53

Ovarian Tumors

CLYDE L. RANDALL, M.D.
Buffalo, New York

A DISCUSSION of ovarian tumors requires con-
sideration of a variety of important and in-
teresting neoplasms. We will not attempt to
review figures indicating the incidence of these
varied tumors or consider the ages at which
each is most likely to be discovered. There
seems little reason to describe findings which
might suggest that a cystoma is of one type or
another. We will try, however, to review some
of the points concerning ovarian tumors which
may be of interest and of some practical value
to the physician in general practice.

There should be little need to emphasize the
importance of first determining, especially when
the patient is young, whether the tumor is a non-
neoplastic dysfunctionally cystic enlargement or
a true neoplasm. Particularly, when the tumor
is no larger than the proverbial lemon, re-exam-
ination after a few weeks usually provides a sat-
isfactory means of differentiating cystic ovaries
and true cystomas. In younger women, when
ovarian enlargement has been observed to per-
sist through several menstrual cycles, the pres-
ence of a true neoplasm becomes evident and
laparotomy is indicated. If the patient is over
40, however, it is well to remember that dys-
functional cysts are less likely. Palpation of the
ovaries is particularly important after the meno-
pause, when, unfortunately, postmenopausal
changes make the ovaries difficult to outline.
In older women, any enlargement should be
regarded with apprehension, and laparotomy is
indicated if the impression of appreciable ova-
rian enlargement seems
tion under anesthesia.

Irregular bleeding is more apt to occur when
ovarian enlargement is due to dysfunctional cys-
tic changes and less likely with truly neoplastic
enlargement of the ovary. Nonfunctioning tu-
mors of the ovary are not apt to be associated
with abnormal uterine bleeding.

clyde l. randall is professor of obstetrics and
gynecology at the University of Buffalo School of
Medicine.

Paper presented at the third annual seminar,
Huron Road Hospital, Cleveland, Ohio, February
26, 1957.

confirmed by examina-

It is interesting that tumors have been report-
ed to develop more frequently in the left ovary
than in the right — in a ratio approximating 4
on the right to 3 on the left side.

It would be well to remember that chocolate
cysts due to ovarian endometriosis may be pres-
ent, though the patient does not complain of
the acquired type of dysmenorrhea so frequently
associated in our minds with endometriosis.
When chocolate cysts of the ovary are encoun-
tered and dysmenorrhea has been a complaint,
it is equally important to remember that ovarian
resection alone will probably not relieve the pa-
tient’s dysmenorrhea. Such menstrual pain is
usually due to adenomyosis, and a presacral
nerve resection or hysterectomy is usually nec-
essary when dysmenorrhea is a major complaint.

While chocolate cysts are the most frequent
neoplastic cause of ovarian enlargement, the der-
moid or the benign teratoma, as it is now so
frequently called, is the type of true cystoma
most frequently encountered. Teratomas are not
all dermoids, and all are not benign. Too often,
a solid teratoma is regarded as likely to be ma-
lignant, and a cystic tumor is considered prob-
ably benign. Actually, a solid teratoma may
prove to be benign, and the possibility of squa-
mous-cell carcinoma in a dermoid should not be
forgotten. Over 100 such cases have been re-
ported and, though the incidence is difficult to
determine, it must be something approximating
1 per cent. The frequency with which dermoids
involve both ovaries has been the subject of
considerable discussion. The larger series of
reported cases suggest the probability that bi-
lateral occurrence is less than 15 per cent.

The eystadenomas are probably the next most
frequent group of ovarian neoplasms. Here, a
careful appraisal becomes increasingly impor-
tant. So-called simple cystomas are usually uni-
locular and often pseudomucinous. As soon as
an ovarian cvst has been removed from the ab-
domen, it should be opened in order to deter-
mine if the lining is smooth or grossly papillary.
Removal without rupture of the cyst helps pre-
serve surgical ego and is generally considered
desirable. This practice involves removal of the
entire ovary, however, and disregards the possi-

54

THE JOURNAL-LANCET

bility of resecting a benign cystoma from unin-
volved perfectly normal portions of the ovary.
When the woman is under 50 years of age and
the tumor appears to he unilateral, the chance
of malignancy is slight. Under such circum-
stances, spill of the cyst content into the peri-
toneal cavity as a residt of attempting to pre-
serve a portion of the ovary is hardly to be re-
garded as a technical tragedy. We have repeat-
edly noted that pseudomyxoma peritonaei de-
velops only when a tendency to penetrate the
capsule and implant spontaneously onto adja-
cent peritoneum was evident the first time the
abdomen was opened. We have to date observed
no instance in which the spill of the contents
of a pseudomucinous cystoma resulted in the
peritoneal seeding of an implanting tumor if that
tendency was not evident when the abdomen
was first opened. Whenever the tumor is uni-
lateral, the opposite, apparently uninvolved look-
ing ovary should be bisected in order to make
certain that it shows no evidence of beginning
neoplasm before we decide it can be preserved
as the involved side is removed.

If the tumor is bilateral, the chances of malig-
nancy are increased. Should bilateral cystomas
appear benign, however, it might be particularly
desirable to preserve as much ovarian tissue as
possible. Usually, the appearance of one side
suggests the possibility of resection rather than
of oophorectomy, and it is well to begin on the
side which looks as though the ovarian tissue
would be easier to preserve. If there is no evi-
dence of implantation and there are no adhesions
to the surface, by protecting adjacent structures
with gauze packing, the cystoma can usually be
resected from the ovarian tissue adjacent to the
pedicle and its blood supply. The removed cyst
should then be opened. If the gross appearance
does not suggest malignancy, an attempt should
be made to handle the opposite side in a similar
manner. If the opened cyst shows a grossly
papillary lining, it is better to await the patholo-
gist's opinion concerning the probable malig-
nancy of the neoplasm. If the neoplasm is con-
sidered malignant, the previously preserved
grossly uninvolved portion of the resected ovary,
its adjacent tube, the uterus, the opposite ad-
nexa, and the omentum should be removed.

Some of the less common ovarian neoplasms
present features of unusual interest. The so-
called Krukenberg tumor, for example, always
seems to be remembered, though other more
frequently occurring varieties may have been
forgotten. It is usually bilateral, presents a nod-
ular uneven surface, and is usually free of ad-
hesions. The cut surface shows dense areas alter-

nating with soft myxomatous portions, and, on
histologic section, the characteristic ring cells
are pathognomonic. It is interesting to note that
while Krukenberg1 is generally credited with an
accurate description of both the gross appear-
ance and the histology of this tumor, as originally
reported in 1896, he apparently did not recog-
nize that the tumors were of secondary or met-
astatic nature. Within eight years, however,
others had established the fact that the tumors
Krukenberg had described were usually meta-
static from a primary in the intestinal tract. Per-
haps a “primary” Krukenberg may occasionally
be found. At least, on several occasions, grossly
and histologically typical looking neoplasms
have never developed evidence of a primary
after the ovarian growths were removed.

The incidence of the Krukenberg tumor ap-
proximates 5 per 100 ovarian malignancies. The
practical importance of this tumor is, however,
considerably greater than its incidence indicates.
The mere possibility of this lesion serves to re-
mind us that pelvic neoplasms may be associ-
ated with neoplasms of the bowel. Preoperative
roentgenograms are advisable, and it is often
wise to prepare the patient psychologically, as
well as with antibiotics, for a possible resection
of bowel. A mass, from a clinical standpoint,
considered to be of ovarian origin may, in re-
ality, prove at operation to be of intestinal ori-
gin. This fact quite possibly could be demon-
strated by preoperative roentgenograms, and,
under such circumstances, preoperative prepa-
ration of the bowel with antibiotics would cer-
tainly be desirable. It is well to consider, also,
prophylactic removal of the ovaries when a ma-
lignancy of the bowel, particularly gastric car-
cinoma, is being resected. While this measure
has not been employed sufficiently often to per-
mit its evaluation, at least from a theoretic
standpoint, prophylactic oophorectomy should
be considered as a means of avoiding the sub-
sequent development of Krukenberg tumors.

The so-called functioning ovarian tumors may
have either a feminizing or masculinizing effect
but are often “defeminizing” rather than mascu-
linizing. Among functioning tumors, those with
a feminizing effect predominate in a ratio ap-
proximating 4 to 1. Novak2 has estimated that
granulosa cell carcinoma and the thecomas to-
gether comprise approximately 19 per cent of all
solid malignant growths of the ovary and might
well be suspected whenever relatively solid tu-
mors of the ovary are encountered. In recent
years, reports have suggested that relatively light
irradiation into the pelvis may eventually result
in a significantly increased incidence of femin-

FEBRUARY 1958

55

izing tumors. At present, however, there does
not seem to be a history of irradiation in the
background of a significant number of the pa-
tients in whom granulosa or theca-cell tumors
of the ovary have developed.

When extensive lutein-like changes are evi-
dent, the term luteoma may be employed, but
even when such extensive luteinization is evi-
dent, the biologic effect of such tumors is purely
estrogenic. A present tendency is to regard lu-
teoma as a histologic picture occasionally pre-
dominant in thecomas as opposed to considera-
tion of the luteoma as a separate entity. While
two histologically different neoplasms have been
described, nevertheless, the two may be found
within the same neoplasm. When feminizing
tumors develop in children, “precocious men-
struation" may occur, but it is anovulatory bleed-
ing and such children should not conceive. Evi-
dences of ovulation or the occurrence of preg-
nancy would, therefore, indicate constitutionally
precocious development rather than the develop-
ment of a feminizing tumor.

The malignant potentiality of feminizing tu-
mors remains a question. Novak has suggested
that 25 to 33 per cent of functioning ovarian tu-
mors can be expected to recur at least locally.
Granulosa-cell tumors, though histologically be-
nign, have been reported to recur in the pelvis
fifteen years and more after apparently complete
removal of the primary lesion. In the majority
of instances, when granulosa cell tumors do re-
cur, they do so locally and are clinically of a
rather low grade of malignancy. Occasionally,
granulosa-cell carcinoma may be associated with
the development of abdominal carcinomatosis
and prove rapidly fatal in a manner similar to
primary carcinoma of the ovary. Thecomas are
relatively benign. Feminizing tumors may, how-
ever, contribute in a less direct manner to the
development of malignancy in the female. In
postmenopausal women, the long sustained pro-
duction of estrogen by feminizing tumors occa-
sionally precedes the development of endomet-
rial carcinoma. Thecomas may be particularly
potent in their estrogenic activity and have most
frequently been associated with the development
of adenocarcinoma in the uterus.

Tumors causing defeminization or masculini-
zation may be any of 4 types: (1) arrhenoblas-
toma, (2) adrenal-like tumors, (3) masculinovo-
blastoma, and (4) hilus cell tumors.

The less endocrinologically active tumors, with
a so-called defeminization effect, account for
amenorrhea and regression of the breasts. The
more actively androgenic neoplasms produce
hirsutism, enlargement of the clitoris, and deep-

ening of the voice. Therefore, some type of an-
drogenic tumor might well be suspected when
a woman, previously feminine in appearance,
begins to exhibit changes suggestive of either
defeminization or masculinization. As a general
rule, such changes tend to regress after removal
of the androgenic neoplasm.

The arrhenoblastoma is the classical example
of the masculinizing tumor and histologically
suggests attempts to reproduce testicular tissue.
Many such tumors are nonfunctioning, however,
which observation Novak suggests may indicate
that the smaller, nonfunctioning ones may be
but an embryonic vestige of testicular tissue.
Some of the more undifferentiated arrhenoblas-
tomas have been considered sarcomas.

The adrenal-like tumors of the ovary have
been considered by Novak to be the result of
adrenal cell inclusion within the ovarian anlage,
and they are of importance because their devel-
opment may produce the clinical picture of a
Cushing’s syndrome, similar to that observed
with the development of a tumor of the adrenal
cortex.

The masculinovoblastomas, once called “mas-
culinizing luteomas” are relatively rare — less
than 30 cases have been reported to date. Fre-
quently, the tumors are so small that an adnexal
mass is not evident but, when discovered, appear
encapsuled, present a yellow surface on cut
section, and microscopically suggest a luteoma
or hypernephroma. They are associated with
increased 17-ketosteroids, amenorrhea, hirsutism,
enlargement of the clitoris, and hypertension.

Evidence of defeminization should also sug-
gest the possibility of a so-called hilar cell tumor
of the ovary. These may be particularly difficult
for the clinician to detect, since reported eases
have involved tumors no larger than a normal
ovary. Nests of large ovoid cells similar to the
Levdig cells of the testes may develop in the
medullary portion of the ovary. Though mascu-
linization may develop, it appears without the
hypertension characteristic of the maseulinovo-
blastoma.

Meigs’s3 classical description of the syndrome
which bears his name has undoubtedly stimu-
lated the clinicians’ interest in the possibility of
determining the nature of ovarian neoplasms by
preoperative study of the patient. Meigs’s ob-
servation that benign fibromas of the ovary could
be associated with ascites and hydrothorax has
resulted in many attempts to recognize the en-
tity. Many have considered cystic tumors with
associated ascites and hydrothorax as examples
of this syndrome. The triad of pelvic tumor,
ascites, and hydrothorax has been reported with

56

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benign ovarian cystomas, leiomyomas, teratomas,
malignancies of the ovary, with trauma, and with
carcinoma of the pancreas. Meigs believes, how-
ever, that the syndrome should be restricted to
the triad of: (1) a fibroma-like tumor of the
ovary, (2) ascitic fluid in the abdomen and a
hydrothorax, and (3) disappearance of both the
ascitic fluid and the fluid within the chest after
the ovarian fibroma or fibromas have been re-
moved. He has, moreover, recently re-empha-
sized his criteria, while at the same time giving
credit to two older clinicians who, since Meigs’s
original description, had been recognized as hav-
ing contributed published reports regarding this
syndrome some years previously.

Meigs’s syndrome is so well known that when
internists and roentgenologists recognize hydro-
thorax, they often wonder whether a pelvic neo-
plasm could account for the fluid in the chest.
I have yet to find an unsuspected fibroma of the
ovary when discovery of a hydrothorax was the
first evidence of pathology. We have observed
two typical instances of Meigs’s syndrome, but,
in each instance, there was a clinical suspicion
of ascites, the pelvic tumor was readily identified
on examination, and the hydrothorax was the
last feature of the syndrome to be identified.
The source of the ascitic fluid was long a source
of considerable speculation. It now seems gen-
erally accepted, however, that the fibromas are
edematous and leak fluid into the peritoneal
cavity, from which it finds its way above the
right diaphragm.

Gynecologists of considerable clinical experi-
ence have perpetuated a belief that solid tumors
of the ovary are more likely to cause pain than
cystomas, though, personally, I have yet to see
the patient whose complaint of pelvic pain was
explained by the discovery of a fibroma in her
pelvis.

When the appearance of the cystoma suggests
malignancy and it appears possible to remove
both adnexa and the uterus, it is well to make
as clean and complete an excision as possible.
Excision of parietal peritoneum, particularly in
the cul-de-sac and along the posterior surfaces
of the broad ligaments, usually results in a much
more adequate resection. Exenterations have
taught us that a pelvis so denuded quickly re-
peritonealizes, or a redundant loop of sigmoid
may often be utilized to at least partially cover
the floor of the dissected pelvis. When ovarian
malignancy appears locally invasive, Kottmeier4
has stressed the advisability of saving the uterus.
If involvement of the mesosigmoid and para-
rectal tissues suggests the probability that ex-
cision of the tumor will be incomplete, he be-

lieves it is better to preserve the uterus as a
point from which unremoved tumor can be ir-
radiated. This modification is recommended,
however, only when it is suspected that removal
of the malignant tissue will be incomplete.

In the management of ovarian carcinoma,
some attempt to classify or clinically “stage” the
malignancy would be helpful from a prognostic
standpoint. A simple but clinical and practical
classification would be somewhat as follows:

Stage 1 . Carcinoma limited to one ovary.

2. Carcinoma involving both ovaries but with no
grossly appreciable extension outside the uterus and
adnexa.

3. Ovarian malignancy considered inoperable because
of obvious extension into adjacent tissues.

4. Inoperable ovarian carcinoma with evident carcino-
matosis of the abdomen, involvement of the omentum,
extensive peritoneal implantation, and/or distant metas-
tasis.

The dissemination of ovarian malignancy is
not inhibited by even so much as a peritoneal
covering over the ovary. Early dissemination is
likelv, and the omentum is involved early. Its
removal at the time of initial surgery is a pallia-
tive measure worth consideration, for the de-
velopment of a large “omental cake” often adds
considerably to abdominal distention and dis-
comfort. While fairly extensive pelvic dissection,
including the stripping of parietal peritoneum
off of the bladder, broad ligaments, and cul-de-
sac may contribute to a more complete excision
and a better clinical result when the lesion ap-
pears operable, resection of involved loops of
bowel and heroically extensive surgery in the
pelvis seem to have no place in the management
of ovarian malignancy. The surgeon’s sense of
frustration is based upon the fact that ovarian
malignancy usually and rapidly involves tribu-
taries of the portal system. Extension into the
upper abdomen and liver seems inevitable no
matter how extensive the pelvic excision might
have been.

Occasionally, the surgical procedure may have
been completed before the malignant character
of an ovarian tumor was recognized. When the
diagnosis of carcinoma of the ovary is a post-
operative surprise and only one ovary has been
removed, more adequate surgery should not be
delayed. A second operation, with removal of
the uterus, remaining adnexa, adjacent portions
of the peritoneum, and the entire omentum, im-
proves the possibility of a longer survival.

The effectiveness of postoperative irradiation
is not predictable, but, in the individual case,
its use may seem of great benefit. A full thera-
peutic trial is indicated. The use of intraperito-
neal colloidal gold as a source of irradiation
should be limited to cases in which spill has

FEBRUARY 1958

57

occurred or purely prophylactic irradiation is
considered advisable. If there are any remnants
of tumor in the abdomen, external irradiation is
far more effective. The irradiation from activat-
ed gold may be sufficient to inhibit the reforma-
tion of ascitic fluid, and it is very well tolerated
by the patient, but it seems quite inadequate
when grosslv appreciable foci of tumor indicate
treatment. Recent reports seem to indicate that
some of the newer “nitrogen mustards” are much
more effective when recurrence is evident, and
ascitic or pleural effusion adds greatly to the pa-
tient’s discomfort.

The so-called mesonephric carcinomas of the
ovary continue to be a source of some confusion.
As a rule, this tumor is relatively large, presents
a round, smooth surface, and, on cut section,
appears semisolid except for pseudocystic areas
of degeneration frequently noted within an oth-
erwise smoothly solid neoplasm. The growth
tends to break through its capsule. Malignancy
is evident when penetration of the capsule and
metastatic implantation occur. Metastatic nod-
ules have a noticeably yellow appearance. Ap-
proximately half of the reported cases have been
highly malignant, while many others have evi-
denced a surprisingly benign course. These tu-
mors frequently develop after the menopause
and may be associated with the development of
ascites. The term mesonephroma was first sug-
gested in 1939 by Schiller5 who noted that the
histology suggested rudimentary glomeruli in
some areas. Schiller also noted that this neo-
plasm may also be found as an intraligamentous
tumor, which characteristic has been particu-
larly emphasized by Gardner and associates/’
The latter have recognized, however, that these
neoplasms are of mesonephric rather than of
ovarian origin.

The various tvpes of neoplasms arising in the
female pelvis, which were thought to be of me-
sonephric origin, have recently been described
by Novak7 as follows:

1. The classical mesonephroma of Schiller, which may
seem to be arising in the ovary.

2. The clear cell carcinomas of the ovary, which may
coexist witli or develop within a mesonephroma.

3. Tire mesonephric tumors developing within the
broad ligament.

4. Cervical and vaginal tumors of mesonephric origin.

When the latter develop in the cervix, the his-
tologic appearance suggests a cystadenoma or
an adenocarcinoma. Development of the more
myxomatous of the mesonephric tumors within
the vagina may result in a papillary growth con-
fused with sarcoma botryoids.

Increased knowledge of the nature of ovarian
neoplasms and improved management of the

patients affected are unfortunately evident only
when the neoplasms are benign. To date, little
progress has been made toward decreasing the
number of deaths due to ovarian malignancies.
As we contemplate possible approaches to this
problem, the futility of frequent and periodic
routine pelvic examination might well be recog-
nized. Annual pelvic examination appears to
offer little hope of detecting malignancies of the
ovary in a curable state. During the years Mac-
farlane* and her co-workers repeatedly examined
a number of volunteers who came in regularly
every six months or every year, among 18,000
such routine examinations, 6 carcinomas of the
ovary were detected. Among the 6, onlv 1 was
considered early enough to be curable. Every
study of this problem emphasizes the rapidity
with which ovarian malignancy progresses to an
inoperable stage. Available data suggest the
probability that, if all women were examined
once a year, an ovarian malignancy would have
developed in approximately 3 among each 10,000
during the year, but that only 1 of the 3 neo-
plasms would be in a favorably early stage of
its development.

Small wonder then that there is an increasing
tendency to take out ovaries on a prophylactic
basis. The risk of leaving the ovary at the time
of hysterectomy has been the subject of consid-
erable discussion. Grogan and Duncan,9 of Bos-
ton Free Hospital, stated that complaints or a
pelvic tumor developed in 33 per cent of patients
with ovaries preserved at the time of hysterec-
tomy, which was regarded as evidence that the
ovaries should have been removed. Fagen and
associates,10 of Chicago Presbyterian Hospital,
found that 7 per cent of 172 women who came
into their hospital for treatment of an ovarian
carcinoma had previously had a pelvic laparoto-
my at which time the ovaries might have been
removed. Such observations suggest the advisa-
bility of attempts to calculate the risk of preserv-
ing the ovary.

Among the 9 per 1,000 women now destined
to develop an ovarian carcinoma, we might well
ask — how many of those ovarian carcinomas
could we prevent by removing both ovaries each
time a hysterectomy is indicated? This obvi-
ously woidd depend upon the incidence of hys-
terectomy, but, if it is 10 per cent, we coidd
reduce the over-all incidence of ovarian carcino-
ma by 10 per cent, that is, from 9 to approxi-
mately 8 cases per 1,000 women simply bv re-
moving both ovaries each time a hysterectomy
is indicated. We would expect the incidence of
ovarian carcinoma, among women previously
subjected to hysterectomy, to be the same as

58

THE JOURNAL-LANCET

among the population at large, namely., approxi-
mately 9 cases per 1,000 women. Actually, Allen
followed 2,097 women to see how many had de-
veloped a carcinoma of their preserved ovaries
and found not the 19 cases we would expect in
such a group from the incidence of ovarian ma-
lignancy among the population at large but 63
cases, an incidence 3 times what we might ex-
pect. Well might we ask: (1) If women subject-
ed to hysterectomy are predisposed to the for-
mation of malignant neoplasms of the ovary by
changes which follow hysterectomy? (2) if the
same benign uterine neoplasms or the loss of
uterine support or the hemorrhagic menstrual
tendencies— which originally indicated hysterec-

REFERENCES

1. Krukenberg, F.: Ueber des Fibrosarcoma Ovari Mucocellu-

lar ( Carcinomatodes ). Arch, gynak. 50:287, 1896.

2. Novak, E.: Hormone-producing ovarian tumors. Obst. &

Gynec. 1:3, 1953.

3. M^igs, J. V.: Pelvic tumors other than fibromas of ovary

with ascites and hydrothorax. Obst. & Gynec. 3:471, 1954.

4. Kottmeier, H. L.: Classification and treatment of ovarian

tumors. Acta obst. et gynec. scandinav. 31:313, 1952.

5. Schiller, W.: Mesonephroma ovarii. Am. J. Cancer 35:1,

1939.

6. Gardner, G. H., Greene, R. R., and Peckham, B. M.:
Normal and cystic structures of broad ligament. Am. J. Obst.
& Gynec. 55:917, 1948.

tomy among these women— resulted in a greater
than average incidence of ovarian malignancy?
or (3) Is such sampling inadequate? Should such
figures be regarded as significant?

The answers to many such important ques-
tions await data that careful observation should
eventually provide. Since, at the present time,
there seems to be no means of recognizing which
women are predisposed to the development of
ovarian carcinoma, the question remains one of
deciding whether a 1 per cent chance of a ma-
lignant tumor of the ovary justifies prophylactic
oophorectomy when laparotomy is performed for
other indications and the woman is approaching
her climacteric.

7. Novak, E.. Woodruff, J. D., and Novak, E. R.: Probable

mesonephric origin of certain female genital tumors. Am. J.
Obst. & Gynec. 68:1222, 1954.

8. Macfarlane, C., Sturgis, M. C., and Fettefman, F. S.:
Results of experiment in control of cancer of female pelvic
organs and report of 15-year research. Am. j. Obst. & Gvnec.
69:294, 1955.

9. Grogan, R. H., and Duncan, C. J.: Ovarian salvage in rou-
tine abdominal hysterectomy. Am. J. Obst. & Gynec. 70:
1277, 1955.

10. Fagen, G. E., Allen, E. D., and Klawans, A, H : Ovarian
neonlastns and repeat pelvic surgery. Obst. & Gynec. 7:418,
1956.

Benign congenital hypotonia in infants may be manifested by generalized
weakness of the skeletal muscles. The nonprogressive congenital neuromus-
cular abnormality should be differentiated from amyotonia congenita. Phys-
ical examination shows that the child is limp. Neuromuscular development is
delayed. Weakness may be greater in some muscle groups or may be uniform
throughout the trunk and limbs. No pseudohypertrophy is observed.

Electrical testing of muscles bv the faradic-galvanic method reveals no
abnormality; electromyograms show excessive polyphasic and short-duration
potentials during voluntary contraction of affected muscles. No pathogenic
alterations are observed in muscle biopsy specimens.

In 8 children with benign congenital hypotonia who recovered completely,
fetal movements had been normal. The deep tendon reflexes could be elicited
but were sometimes diminished. Intellectual development was normal. Muscle
tonus returned to normal bv the fifteenth year of life or before.

In 9 patients, symptoms were more severe; fetal movements had been
reduced in 1 case. Deep tendon reflexes were lacking in 3, depressed in 4,
normal in 1, and brisk in 1 patient. Intercostal weakness was noted in 3 in-
stances. Some muscular weakness persisted in these patients.

John N. Walton, M.D., National Hospital, London. 1. Neurol., Neurosurg. & Psycbiat. 20:144-
154, 1957.

FEBRUARY 1958

59

Colic in Infancy

CHARLES E. SNELLING, M.D.
Toronto, Ontario

Colic in infancy is one of those very useful
terms like “Hu” and “constitution,” which are
very specific diagnoses in the minds of the laity
but very broad in their compass when used by
the profession. When this diagnosis is made, it
is accepted by the parents and they know that
it is something they must “put up with” for three
to five months and that the child will recover.

Colic has been defined in some texts by a
description of the symptomatology as a condi-
tion characterized bv crying, drawing the legs
up, distention of the abdomen, and expulsion of
gas by mouth, rectum, or both. These same ar-
ticles also state that the condition usually lasts
three to five months. The first time the term
came to my attention, shortly after entering
practice, was from a grandmother who sagely
stated the new baby had “three months' colic.”
Although it may be necessary to use this term
or so-called diagnosis, it is a mistake to accept
the situation as inevitable. From personal ex-
perience, it has frequently been possible to find
other solutions for the etiology.

The causes of feeding or nutritional disturb-
ances in infancy may be divided into some 7
categories. In order of their frequency they are:

1. Infections, acute or chronic

2. Congenital anomalies and incidents associ-
ated with birth

3. Environmental conditions

4. Feeding disturbances, quantity or quality

5. Psychoneurotic disturbances

6. Allergy

7. Endocrine and metabolic disturbances
Infections. The onset of infection is the most
common cause of “colic," abdominal distention,
and so forth in a previously healthy infant with
uneventful feedings. Infections account for the
largest number of digestive disturbances.

Congenital anomalies. Congenital anomalies
involve anv part of the body. Those of the heart
are frequently associated with symptoms attrib-

charles e. snelling is associate professor of pedi-
atrics at the University of Toronto and The Hospital
for Sick Children, Toronto.

Read at the Canadian Medical Association meet-
ing in Edmonton, Alberta, June 19, 1957.

utable to the gastrointestinal tract, which could
be called “colic.” The gastrointestinal tract fre-
quently has stenosis, bands, or malrotation which
may produce these symptoms. One of the most
frequently overlooked is the rectosigmoid region.
Two conditions in this area require special em-
phasis.

The history of a baby reveals spells of crying,
distention, and gas, which are often associated
with meals. This fussy period occurs after meals
and often is associated with some straining and
attempts at evacuation which may be successful.
If one asks if there is trouble with bowel move-
ments, the answer is frequently “No, the baby
has frequent passages.” The character of the
movement may be loose or ribbon-like. This in-
formation is obtained only by direct questioning.
Rectal examination should always be done on a
“colicky” baby unless an adequate cause for the
condition can be found otherwise. The first con-
dition that may be found is a tight fibrous rectal
opening about the size of a lead pencil. The
rectum in a young baby need not be larger than
this, but it may be dilated slowly to the size of
a small index finger. In this condition, there is
a fibrous ring inside the sphincter. When this
has been stretched, in many instances, the “colic”
immediately clears. It is frequentlv necessary to
dilate the rectum on two or three occasions sub-
sequently at weekly intervals.

The second condition found in this area is the
so-called redundant sigmoid. The descending
colon usually curves to the right across the pelvis
and then back to the rectum. In this type of
case, the sigmoid curves across to the right, then
down into the pelvis, back up, and down into the
rectum, forming a very sharp S curve similar to
a sewer trap. Examination by rectum reveals an
emptv area in the rectum, but fecal matter can
be felt in the pelvis in the bowel immediatelv
adjacent to the rectum and packed well into the
pelvis. After advancing the finger up around the
first bend, a large quantity of stool is immediate-
lv released. In this type of case, the mother in-
variably says that the baby has regular move-
ments, but the fact is that the baby is one or
two days late. The stool that is passed today is
pushed along by the fecal material behind it so

60

THE JOURNAL-LANCET

that the baby’s sigmoid and colon are constantly

full.

This condition invariably rights itself as the
baby’s trunk becomes elongated, thus pulling the
sigmoid out of the pelvis, but it may last as long
as two years. This type of patient is relieved
by an enema of baking soda, M to 1 tsp. in 4 to
10 oz. of water. This straightens out the trap-
like effect in the rectosigmoid and usually gives
relief for about two days if the enema has been
effective. Suppositories or soap sticks should
never be used. They only make the condition
worse and possibly lead to the development of
prolapse. An unexplained but frequently dra-
matic procedure in treatment of this condition
is the use of the barium enema. It is possible
that the heavy solution and pressure with palpa-
tion and manipulation necessary to properly vis-
ualize the bowel forces the sigmoid out of the
pelvis and straightens it. Invariably, when the
barium enema is administered correctly, the
radiologist is unable to demonstrate the sigmoid
colon packed down in the pelvis, but, peculiarly
enough, the child’s symptoms nearly always dis-
appear after this procedure. This is a situation
in which a diagnostic measure acts in a thera-
peutic way similar to the demonstration and re-
duction of intussusception.

Incidents associated with birth, such as cere-
bral damage from hypoxia, edema, or hemor-
rhage, are frequently unrecognizable in the early
period of life. It has been the experience of ail
pediatricians to discover after six months or a
year that a baby who is high-strung and cries
all the time is mentally retarded because of cere-
bral palsy. Many of these infants were treated
for colic, hypertonia, and other conditions until
the true underlying cause became manifest.
There is no way of recognizing mental deficiency
in the first few months of life except, possibly,
from an electroencephalogram, but every crying
baby could not be subjected to this procedure.
However, with a history suggestive of some
problem at the time of birth, the possibility of
an abnormal mental condition should be kept in
mind. In addition, unrecognized fractures may
cause symptoms suggestive of colic.

Environmental conditions. If environmental
conditions were successfully eliminated, pediat-
rics in this country would certainly become en-
tirely a consulting practice.

These conditions include the way the baby
is handled and fed, the temperament of the
others in the home, the home itself, and all the
other things which impinge on this new life
which has been taken from a place of complete
protection in the uterus to one where it must

fight against outside factors for its very exist-
ence. True, this struggle is aided by others, such
as parents, nurses, and doctors, but their efforts
may produce stimuli which upset the baby.
These elements are the largest cause of colic in
the very young baby.

Temperature and humidity are usually not big
factors. The most frequently encountered prob-
lem occurs in the artificially fed baby. Mothers
have read the books and are impressed by the
danger of a nipple with too large a hole. Nipples
are invariably sold with holes in them so small
that even a husky grown man would have diffi-
culty in extracting a feeding. The mothers say
the feeding goes fast enough. Even heat the
bottle up and turn it over and a spurt of liquid
is seen. However, after that first fluid goes out
due to the pressure of the heated air in the
bottle, nothing follows. One is always impressed
by the size of the nipple holes in nurseries and
pediatric wards where the nurses do not have
all day to feed a baby. The babies do not have
colic or do they choke on or vomit feedings if
fed intelligently. The mother should be instruct-
ed how to use the bottle properly, and it is well
to give a practical demonstration. The nipple
should have dual holes large enough to see
through each a letter about the size of a small
“o” on an ordinary typewriter. Even if the feed-
ing pours through the nipple, as it sometimes
does in nurseries, nothing untoward happens
if it is removed from the baby’s mouth after a
bubble or two to give the baby a chance to
breathe. The small-holed nipple leads to air
swallowing, colic, and vomiting. This simple
procedure usually endears the pediatrician to
the family for life, since, after many sleepless
nights, the parents are greatly relieved to have
a quiet, satisfied baby.

The next type of disturbance might be termed
“paternal colic.” Pediatricians find that much
of their practice related to this condition comes
in the evenings or weekends. This is partly due
to the fact that the father is home at such times,
and, wishing to have his share of the new baby,
handles the infant more than he should. Another
situation causing this type of colic occurs when
the father becomes annoyed when his comfort
and relaxation are disturbed. The mother then
becomes tense, and the baby is quick to sense
this reaction. At this point, the father is impa-
tient and sends for the doctor.

This is the period of unexplained evening fussy
session, which many babies have from 6 to 10
p.m. In breast-fed babies, one can say that the
mother is tired or not producing sufficient food,
but it occurs in nonbreast fed babies as well.

FEBRUARY 1958

61

Another possibility is that a time of increased
activity of the mother during fetal life may have
conditioned the baby. Another possibility is the
increased tension, activity, and noise in the home
when the father and other children are there.
This is a condition that has no adequate ex-
planation or cure. The parents should be told
that they are fortunate that this period does not
occur from 10 p.m. to 2 or 6 a.m.

Tense parents can generate tension in the baby
by constantly fussing over him. It is frequently
a good therapeutic measure to take the baby out
of his environment on the pretext of making
tests or trying new feedings. After a few days
of rest, parents often settle down and have a
perfectly tranquil child.

Overcrowding and housing conditions have
led to much so-called colic. When the family
live with in-laws or in flats or apartments, fear
of disturbing others is cause to pick the baby
up when he cries. When put down, he cries
again. This is a conditioned situation, which
can, of course, be cured by moving to a sepa-
rate dwelling and allowing the baby to cry it out.

In all of these situations, it is often necessary
to give the baby a sedative, such as % gr. of
phenobarbital and 1/1200 gr. of atropine before
meals, for a while. Frequently, the parents need
the sedative, but a quiet baby nearly always
reacts indirectly on the parents. It has also been
observed, in some instances, that when the baby
settles down, the mother then becomes worried
because he is too quiet. Little can be done with
this type of parent.

Colic is also caused by such factors as pins
pricking the baby, soiled clothes, too warm
or too cold an environment, too much clothing,
and so forth.

Feeding disturbances. Feeding is more fre-
quently wrongly blamed for colic than any other
cause. Except for quantity, it usually does not
cause distress. At the present time, a knowledge
of adequate feeding is so universal from med-
ical advice, press periodicals, and advertising by
the food companies that it is most unlikelv for
a baby to receive a feeding which is qualitatively
inadequate. Thus, if an artificially fed baby is
upset, it is not the feeding that is at fault but
the baby. An unusual feeding may be necessary
in some instances. It is most important to em-
phasize these facts to the parents, and this ap-
proach may also save the phvsician some embar-
rassment. Breast milk also, for practical pur-
poses, causes no qualitative disturbance. Over
many years, we have known of only two infants
who coidd not take breast milk in spite of the
fact the mothers had large quantities.

Quantitative disturbance is very common, par-
ticularly in the breast-fed infant. Underfeeding
in these infants is characterized bv vomiting,
colic, gas, and frequent bowel movements. The
gas that is swallowed, plus the hunger, cause
the first symptoms, and the frequent movements
are a result of passages of intestinal juice from
the rectum. The baby does not gain weight.
This condition is corrected by increasing the
breast milk supply, if possible, by increased
stimulation and the use of a supplementary feed-
ing. It is frequently necessary to put the baby
on an artificial feeding entirely.

Overfeeding in the breast-fed baby causes a
similar set of symptoms: vomiting, colic, gas, and
frequent movements. In this situation, the move-
ments are large and the baby usually has had a
rapid gain in weight. This condition can be cor-
rected by cutting down the feeding by allowing
the baby less time at the breast. Most babies
who suffer from this disturbance are large, vig-
orous, and nurse too rapidly. A small amount
of water, ’2 to 1 oz., given before feeding time,
usually corrects the trouble. It is not wise to try
to force the mother to curtail the number of
feedings because law of supply and demand
nearly always works out a solution in a week or
two. If the physician interferes, the mother often
cuts down the nursing time too drastically with
a result that soon there is no breast milk.

Underfeeding and overfeeding in the artifi-
cially-fed infant may produce the same symp-
toms, but this is very unusual.

Psychoneurotic disturbances. Among the psy-
choneurotic disturbances are hypertonia and
idiopathic colic. Hypertonia is characterized by
a crying, high-strung, vomiting baby with all the
symptoms of colic. The true hypertonic baby is
relieved with atropine, with or without pheno-
barbital, before feedings.

Idiopathic colic supposedly lasts three to five
months and is the disturbance for which a cause
cannot be found. This group of infants is fairly
small.

Allergy. Food allergy is not an infrequent
cause of colic. There may be other symptoms,
such as vomiting and/or diarrhea. The cause is
difficult to determine and, I feel, frequently over-
looked. The condition can be corrected by chang-
ing the feeding from cow’s milk to goat’s milk
or to preparations such as soybean suspensions
and protein hydrolysates.

Endocrine and metabolic disturbances. In
endocrine and metabolic disturbances, feeding
difficulties are occasionally seen, some of which
have the symptomatology of colic. Tetany is
frequentlv manifested by a very irritable, high-

62

THE JOURNAL-LANCET

strung babv. In cases of delayed so-called tetany
of the newborn, these may be the only symp-
toms for some time. In the adrenogenital syn-
drome, symptoms of colic often occur both in the
prerecognized stage and posttreatment phase.

The symptoms of scurvy might be misinter-
preted as colic. The baby is irritable and cries,
particularly when handled. This condition is due
to lack of vitamin C and is increasing. We have

30 to 50 cases a year at The Hospital for Sick
Children.

The foregoing are some of the conditions that
may give rise to symptoms called colic. One can
see that many must be eliminated before it can
be said that a child has colic. Many of these
conditions are amenable to treatment. It is con-
sequently important to carry out a careful dif-
ferential diagnosis.

After bacterial meningitis has been successfully treated in infants and
children, subdural effusion may lie due to excessive withdrawal of cerebro-
spinal fluid for diagnostic purposes.

In children, 10 to 15 ce. of spinal fluid represents one-fifth to one-third
of total fluid volume. Withdrawal of this amount of spinal fluid may cause
separation of the dura from the arachnoid, with tearing of the bridging veins
in the subdural space and consequent subdural hematoma. When this blood
liquefies, osmotic tension draws spinal fluid into the subdural space. Probablv,
onlv 1 tap should be done and no more than 3 cc. of fluid removed.

When the fluid withdrawn was limited to 3 ec., only 3 of 27 patients had
subdural effusions. In contrast, effusion occurred in 9 of 20 infants from
whom larger volumes of fluid were withdrawn.

Jonathan M. Williams, M.D. and Harold Stevens, M.D., Children’s Hospital, Washington,
D.C. J. Intemat. Coll. Surgeons 27:590-594, 1957.

Pregnant women undergoing valvotomy for correction of mitral stenosis are
in no greater danger than those in the nongravid state in whom the operation
is performed. Therefore, the procedure should he done if pulmonary conges-
tion or edema persists or recurs despite treatment with salt-free diets, complete
bed rest, and mercurial diuretics.

Pulmonary edema is the most important cardiac cause of death in pregnant
women. During pregnancy, increased demands are made on the cardiovascular
svstem because of salt and water retention, rise in blood volume, and aug-
mented cardiac output. Healthy women tolerate the demands, hut patients
with mitral stenosis have considerable rises in left atrial and pulmonary capil-
lary venous pressures.

In 18 pregnant women with mitral stenosis, some of whom were near
death, valvotomy was performed with good results; none of the women died
or had significant postoperative complications related to the pregnancy. Op-
eration apparently caused premature births in 2 instances, and 1 fetus did
not survive.

R. J. Marshall, M.D., and J. F. Pantridge, M.D., Royal Victoria and Roval Maternity hospitals,
Belfast, Ireland. Brit. M. J. 5027:1097-1099, 1957.

FEBRUARY 1958

63

Aii Anesthesiologist’s Approach to Prevention
of Operating Room Deaths

VALENTINO D. B. MAZZIA, M.D.

New York City

Numerous studies1-3 detailing the mortality
associated with surgery and anesthesia have
appeared. Although valuable, these studies have
not provided the practitioner with a regimen
which if followed would tend to decrease the
incidence of cardiac arrest. An excellent study
by Berne and associates4 contains an outline of
the known causes of cardiac arrest. However,
the most fruitful approach is to study isolated
instances in which the cause of death is readily
ascertainable and preventable in the light of
present knowledge and technics and, in turn, to
develop from such a study a program for the
prevention of operative deaths.

From the time the anesthetist is first asked to
assist in the care of a patient until he himself
decides that his services are no longer needed,
many opportunities arise to apply medical acu-
men anesthesiologically in the prevention of op-
erating room deaths. The anesthetist must de-
velop a medical routine exactly as every other
physician does. Such a routine approach should
include the following:

1. Establishment of a physician-patient rela-
tionship.

2. An adequate history of anesthesiologically
relevant material.

3. Proper evaluation of the physical examina-
tion.

4. Pertinent laboratory studies.

5. Preoperative preparation.

6. Extremely close attention to the effects of
drugs which are administered with appro-
priate mechanical and pharmacologic anti-
dotes at hand.

7. Maintenance of the physician-patient rela-
tionship until no further care is required.
Should any of these established steps be ig-
nored, unnecessary death will residt.

Before elaborating on these phases of patient
care, a note on consultation is in order. With

valentino d. b. mazzia is assistant attending anes-
thesiologist at The New York Hospital and assistant
professor of clinical anesthesiology in surgery at
Cornell University Medical College, New York City.

respect to consultation, the agent per se is hardly
ever the determinant of whether the patient sur-
vives. It is the skill of the administrator rather
than the drug he administers that decides the
question of life or death. Unfortunately, many
surgeons and internists are not aware of this
point. The following death illustrates the point.

A 4-year-old boy with known congenital heart dis-
ease was scheduled for filling of deciduous teeth. Pen-
tothal administered by skilled anesthesiologists had
been used twice uneventfully for diagnostic cardiac
studies. The private pediatrician felt that this child
could “take” an anesthetic. A technician administered
rectal Pentothal, sat the child in a dental chair, and
because of restlessness continued with opendrop ether.
After one and a half hours in the chair under ether-air,
the heart stopped. At autopsy, cor triloculare was found.
The administrator and not the agent was to blame in
this case.

Let us go back to the medical routine. First
is establishment of a physician-patient relation-
ship. EckenhofF reports 4 deaths in a ten-year
period at the University of Pennsylvania which
were, in all probability, due to apprehension.
The mechanism of death is obscure, but the
danger is real. The patient’s mental and emo-
tional outlook must be evaluated in advance,
and he must be given premedication in such a
fashion that he comes to surgery at ease. Pa-
tients must be seen as early before operation as
possible.

Second is an adequate history of anesthesio-
logically relevant material. This history must
usually be taken by the anesthetist because the
importance of some of the information, which
means life or death to the patient, is unknown
to internists, surgeons, obstetricians, and pedi-
tricians. For example, what history ever includes
an account of the tvpe of anesthesia a patient
has had in the past? Fortunate is the anesthetist
who can refer back to previous anesthetic rec-
ords which, let us hope, were complete and ac-
curately kept, to learn of a patient’s sensitivity
to premedicants, barbiturates, or depth of anes-
thesia. Often the patient says that he went into
shock after a previous anesthetic or that pulmo-
nary edema developed. This information is vital.

64

THE JOURNAL-LANCET

Eekenhoffr' reports the case of a patient who had
had severe hypertension during a previous sur-
gical procedure and who died after a second
operation. At autopsy, an unexpected pheochro-
mocytoma explained everything.

Another major aspect of the history that must
he obtained is a knowledge of the previous medi-
cation the patient has taken. The drugs which
are important to anesthetists are constantly
changing as new drugs are introduced or as
antidotes to old drugs are found. Until recently,
cortisone administration any time within six
months before surgery was considered an indi-
cation for preoperative medication with cortisone
in order to avoid possible postoperative adreno-
cortical insufficiency. With the development of
intravenous hydrocortisone, which acts very rap-
idly, preoperative cortisone is not necessary
unless the postoperative differential diagnosis
of adrenocortical insufficiency can be confused
with the usual postoperative course, as in cra-
niotomy and thoracotomy. If reserpine has been
given anv time within ten days previous to ad-
ministration of an anesthetic, profound hypoten-
sion may follow with cardiovascualr collapse
and, possibly, death. Other drugs of interest are
chlorpromazine and promethazine. Both of these
drugs interfere with cardiovascular compensa-
tory mechanisms and in overdosage can produce
seizures. An uncommon but important problem
is that of the patient who has had his pituitary
removed in toto for carcinoma or diabetes mel-
litus and, as a result, diabetes insipidus has de-
veloped. Such a patient will be on self-adminis-
tered Pitressin snuff. It is important to discon-
tinue Pitressin at least five to eight hours before
surgery. Thus far, we have had to anesthetize
2 patients in both of whom we were fortunate
enough to discontinue the Pitressin in time. The
anesthetist must obtain and evaluate the pre-
operative history of drug intake. Of course, car-
diovascular, respiratory, and metabolic functions
must be fully appraised.

Third is proper evaluation of the physical ex-
amination. Again, the anesthetist is concerned
with information which is seldom on the chart,
and life may be threatened if it is unavailable.
Maintenance of the upper airway is a special re-
sponsibility. The following illustrates this point.

A 64-year-old male with a tumor of the nasopharynx
was on the operating table for tracheotomy because of
progressive dyspnea and cyanosis due to obstruction of
the upper airway. To control agitation, the anesthetist
I administered 200 mg. of thiopental. The patient lost
consciousness, the airway became completely obstructed,
and he expired before the tracheotomy could be accom-
plished. The error here was administration of a general
anesthetic before the airway was secured.

In this part of the evaluation, the major danger
of emergency anesthesia must be faced, namely,
the full stomach, whether from ingestion of food,
hemorrhage, or intestinal obstruction. The most
common explainable cause of anesthetic death is
vomiting or regurgitation with aspiration and as-
phyxia. This complication may be managed
either by establishing a secure airway with a
cuffed endotracheal tube before the induction of
general anesthesia or by emptying the stomach
before the patient is subjected to general anes-
thesia. Some recommend a nasogastric tube with
a large cuff drawn up against the cardiac sphinc-
ter.

In a case of multiple trauma, intracranial in-
jury or thoracic injury may be first diagnosed by
the anesthetist, especially if the physician in
charge of the patient is devoting all of his atten-
tion to a different area of the body. If either of
these injuries goes unrecognized and an anes-
thetic is administered, let’s say for repair of a
fractured lower extremity, the patient may die
suddenly on the table. Although the following
case is not clear-cut, we feel that death was
caused by superimposing the toxic effects of a
general anesthesia on a cerebral concussion.

A 32-year-old male received a severe beating about
the head while intoxicated. After spending twelve hours
at home, lie walked to the hospital in a daze. Thirty-
six hours after injury, repair of his fractured mandible
was scheduled. A nasotracheal tube was passed under
local anesthesia, and surgery was begun under Pentothal,
nitrous oxide, and oxygen. After one hour of surgery,
the heart stopped. The airway had always been perfect,
and an overdose of anesthetic agents was not apparent.
Autopsy revealed nothing.

The patient’s physical state should be inspect-
ed carefully immediately before the administra-
tion of the anesthetic. Everyone knows of pa-
tients who died in the anesthesia induction room
while waiting for the anesthetist to arrive.
A myocardial infarction may occur at any time.
The sudden onset of signs of congestive heart
failure in the greater or lesser circulations or of
a cardiac arrhythmia is cause for delaying the
surgery until a diagnosis has been established
and the condition has been controlled. The fol-
lowing case illustrates that an anesthetic admin-
istered to a patient with recent cardiac arrhyth-
mia caused her death.

Operation in a 65-year-old white female with carci-
noma of the rectosigmoid was cancelled because an
irregular pulse was noted in the induction room, although
previous electrocardiograms had indicated a normal sinus
rhythm. Further medical evaluation for three days re-
vealed little, since her rhythm again became regular.
Brought up again for surgery, an irregular rhythm was
noted and it was decided to go ahead with ether anal-
gesia. After three and one-half hours of surgery, the
jieart stopped and could not be resuscitated.

FEBRUARY 1958

65

Should there be history of asthma or allergy,
it is incumbent on the anesthetist to listen to the
lungs and to determine the immediate preopera-
tive status of the bronchiolar musculature. At
this point, a word on relative and absolute con-
traindications to anesthesia is in order. We feel
there are never contraindications to essential
emergency surgery, provided the personnel are
competent, anesthesia and surgical equipment
are available, and the patient is prepared as com-
pletely as possible.

There are absolute contraindications to elec-
tive surgery, such as recent myocardial infarc-
tion, acute infectious hepatitis, and relative con-
traindications, such as pulmonary insufficiency.
However, again one prepares the patient and
balances the risk of anesthesia against the neces-
sity of surgery.

The hemoglobin and the hematocrit are cru-
cial. We all know of the soldiers who died be-
cause of rapid administration of Pentothal in
the presence of latent or incipient shock. We are
all aware in civilian life of the syndrome of
chronic shock. In this syndrome, the blood vol-
ume is considerably reduced, but the vascular
system is correspondingly constricted so that
apparent compensation with normal hemoglobin
and hematocrit values exists. However, upon the
administration of a general anesthetic or of a
subarachnoid block, the vasoconstriction is lost
and there is a pronounced deficit in the circu-
lating blood volume. Such patients die because
of hemorrhagic shock. It is even possible in this
situation to set into motion a chain of events
which are practically irreversible.

A 40-year-old woman with terminal carcinoma of the
breast was scheduled for total removal of the pituitary.
Preoperative hemoglobin was 9.1-gm. per cent, and red
blood cells were 2.8 million per cubic millimeter. With
the induction of general anesthesia, consisting of Pento-
thal, oxygen, ether, and Arfonad, her respirations became
shallow, pulse weak, and blood pressure precipitously
fell to a systolic of 60 mm. Hg. All anesthetic agents
were discontinued. Five hundred cubic centimeters of
whole blood were administered rapidly, and oxygen was
Hushed repeatedly. In spite of these measures, heart
action ceased twenty minutes after all anesthetic agents
were discontinued. An irreversible chain of events had
been set into motion in this hypovolemic, myelophthisic,
pancytopenic patient.

Another major consideration is the tempera-
ture. In children, general anesthesia often pro-
duces heat retention which, when added to car-
bon dioxide retention, hypoxia, and to the cere-
bral irritant effects of the agent itself, may result
in convulsions and death. We feel so strongly
about fevers in children that elective surgery in
a child with a fever is always deferred. We
never lower the temperature artificially and then
proceed with surgery. In the case of emergency
surgery, the temperature is controlled by a water
mattress, and the temperature must be lowered
before anesthesia is induced.

Fifth is preoperative preparation. If the pre-
vious four steps are carried out properly, the pre-
operative preparation becomes a logical out-
come. In essence, the object of preoperative
preparation is to improve the physical status of
the patient to the optimum possible point. We
can not cure many conditions, but we can often
restore compensation. In the case of dehydra-
tion and electrolyte imbalance, we begin hy-

Fig. 1. Bag and mask provide
oxygen ventilation. The op-
erator is entering the chest to
perform cardiac massage.

66

THE JOURNAL-LANCET

drating before surgery. In the case of decreased
pulmonary function due to chronic emphysema
with superimposed bronchiolar constriction and
infection, the infection can be partially cleared
up preoperatively and the bronchiolar constric-
tion relieved. The patient in cardiac decompen-
sation can be digitalized. Certainly, in such
cases, our role as physicians first and anesthesi-
ologists second becomes readily apparent.

Six, extremely close attention to the effects of
drugs which are administered and appropriate
mechanical and pharmacologic antidotes avail-
able. We feel that no anesthesia, local or gen-
eral, should ever be administered without certain
minimum equipment at hand and 2 individuals
who are competent to perform resuscitation.
Figure 1 illustrates the type of equipment that
we feel is necessary. Briefly, it includes a means
of administering oxygen under positive pressure
and a means of entering the chest to perform
cardiac massage if necessary. Note that an endo-
tracheal tube is not necessary. Figure 2 shows
that even the oxygen and the mask may not be
necessary. Usually, in this group, deaths occur
because of a belief that the agent or technic is
so safe that no resuscitation whatsoever is ever
needed. For example, in New York, a 20-vear-
old healthy woman expired suddenly after local
injection of 8 cc. of 2 per cent procaine for a
tonsillectomy. No resuscitative efforts were
made. Autopsy was unremarkable. Many pro-
cedures are done under local anesthesia with
no equipment at hand and without 2 people in
attendance who know how to resuscitate. Sooner
of later this neglect leads to unnecessary death.

The other major causes of anesthetic deaths are
absolute or relative overdose of the anesthetic
agent, asphyxia, and reflex cardiac arrest. Al-
ways, prevention depends upon the knowledge
and skill of the anesthesiologist who administers
anesthetic drugs and his close attention to the
response of the patient so that an overdose can
be avoided, oxygen supplied, and carbon dioxide
eliminated.

Last is maintenance of the physician-patient
relationship until no further care by the anes-
thesiologist is required.

The anesthetist’s responsibility does not cease
after the operation. At this time, some problems
fall directly into his province. The patient who
has had a thoracotomy may have a potential ten-
sion pneumothorax. The patient who has had a
nephrectomy or adrenalectomy may have a pneu-
mothorax. It is our practice to transport all pa-
tients who have had thoracotomies from the op-
erating room to the recovery room under oxygen.
The anesthetist must give advice concerning
postoperative sedation and analgesics. Failure
to do so may result in death from an overdose
of morphine. The anesthetist must determine
when he can turn the care of the patient over
to someone less skilled. This decision may be
difficult but should always be conservative. The
anesthetist must stay with the patient as long
as necessary, even if it means delaying the op-
erating room schedule. Many deaths occur in
the postoperative period and, most often, they
occur in an unobserved patient. These can be
frequently ascribed to asphyxia caused by a poor
airway.

FEBRUARY 19.58

67

In conclusion, I would like to stress the im-
portance of studying very closely every death
that occurs in the operating room. In our own
community, these studies go on at various levels
from the day of death and last indefinitely. First,
an autopsy is almost always mandatory before
we can with any certainty state the cause of

REFERENCES

1. Beecher, H. K., and Todd, D. P.: Study of deaths associated
with anesthesia and surgery based on a study .of 599,548
anesthesias in 10 institutions, 1948-52, inclusive. Ann. Surg.
140:2, 1954.

2. Edwards, G„ Morton, H. J. V., Pask, E. A., and Wylie,

W. D. : Deaths associated with anaesthesia — report on 1 ,000

cases. Anaesthesia 11:194, 1956.

3. Stephenson, H. E„ Jr., Reid, L. C., and Hinton, J. W.:

death. The death should be reviewed at the hos-
pital level by the anesthesiologist in charge and
by the surgeon in charge. Ideally, each com-
munity should set up an anesthesia mortality
committee which would review these deaths on
an anonymous but compulsory basis. In this
way, we could learn to prevent needless death.

Some common denominators in 1,200 cases of cardiac arrest.
Ann. Surg. 137:731, 1953.

4. Berne, C. J., Denson, J. S., and Mikkelsen, W. P.: Car-

diac arrest — problems in its control. Am. J. Surg. 90:189,

1955.

5. Eckenhoff, J. E.: Some preoperative warnings of potential

operating-room deaths. New England J. Med. 255:1075,

1956.

Skin grafting procedures can he improved by deferring application of the
graft until a satisfactory bed is prepared, bv early inspection of the graft, and
by use of wet dressings.

Although a fresh surgical wound is the best base for application of a graft,
uncontrollable capillarv bleeding after the excision of giant nevi, old fibrotic
ulcers, burn scars, or large hemangiomas may cause hematoma. Covering the
area with sterile pressure dressings for one or two days, during which time anti-
biotics are given, will create a dry bed. Grafting should be delaved for at
least one day after radical mastectomy. If immediate grafting is done, the
transplanted skin is sutured to the underlying tissue but not to the adjacent
skin flaps, thus preventing the pooling of blood beneath the graft. After op-
eration for parotid tumors or lymphangiomas, two davs or more of salivary or
lymphatic drainage are also advisable before grafting. After excision of radia-
tion lesions and extensively fibrotic areas, longer delay and dailv application
of dressings with a coarse mesh gauze base are desirable to foster granulation.

Earlv inspection of the graft is advisable if complications are suspected.
Drainage of underlying blood, serum, or pus and application of pressure will
often save the graft. Sometimes, sutures must be removed from one edge of
a graft to evacuate a large organized hematoma. Earlv examination will not
dislodge the transplanted skin if ultrafine mesh nylon silk is applied over the
grafted area.

When the viability of a graft is in doubt after the first dressing, wet boric
acid applications for twenty-four hours are often beneficial. This procedure is
not advisable for infants or children with large areas of denuded flesh because
of possible toxic absorption.

Paul W. Greeley, M.D., and John W. Cuhtin, M.D., University of Illinois and St. Luke's and
West Side Veterans Administration hospitals, Chicago. Plast. & Reconstruct. Surg. 19:420-423, 1957.

68

THE JOURNAL-LANCET

Memngococcic Meningitis and
Meningococcemia with Probable
Waterhouse-Friderichsen Syndrome

KENNETH F. SWAIMAN, M.D., and
RICHARD B. RAILE, M.D.

Minneapolis, Minnesota

CASE REPORT

A 13-year-old white boy was first seen at Minneapo-
lis General Hospital on August 4, 1957, with the
chief complaint of vomiting and headache. Two days
prior to admission, he became anorexic and a severe
frontal headache developed. The following morning he
awoke complaining of chills and spent almost the entire
day before admission in bed. His temperature was not
taken, but the chills persisted and he became increas-
ingly anorexic. The night prior to admission he slept
well but awakened confused and lethargic. His mother
noted a rash over his entire body so she took him to the
receiving room of a private hospital where he was re-
ferred immediately to Minneapolis General Hospital. His
past medical history was noncontributory to the present
illness. As far as could be ascertained, he had not been
in contact with any contagious disease. He had mani-
fested no upper respiratory symptomatology.

Initial examination revealed a well-nourished, well-
developed white male who was lethargic and confused.
He responded to simple commands and was able to rec-
ognize his mother. His temperature was 103.4 reetally,
blood pressure was 140/70, respirations were 22, and
weight was 51 kg. He had a rash over his entire body—
a dark, erythematous, blotchy eruption which blanched
on pressure. Few frankly purpuric lesions or petechiae
were noted. There was no evidence of trauma about the
head. The tympanic membranes were slightly dulled,
but there was no definite injection. The pharynx was
slightly injected. There were numerous enlarged bilateral
anterior cervical nodes. The lungs were clear to percus-
sion and auscultation. Examination of the heart revealed
a normal sinus rhythm, no murmurs, and no apparent
enlargement. The abdomen was soft and no abnormali-
ties were noted. Neurologic examination revealed a posi-
tive Brudzinski sign and a suggestive positive Kernig’s
sign. All the cranial nerves appeared intact. The gag re-
flex was present. The fundi did not appear abnormal.
The deep tendon reflexes were all present and equal.
They appeared to be of normal magnitude. Toe signs
were negative.

Between the time of admission and the time of com-
pletion of physical examination (about forty minutes),
the patient became much more restless and incoherent,
and stiffness in his neck and back increased markedly.

kenneth f. swaiman and richard b. raile are asso-
ciated with the Department of Pediatrics of Minne-
apolis General Hospital and the Department of Pe-
diatrics of the University of Minnesota.

A lumbar puncture was performed. The fluid obtained
was grossly cloudy and the opening pressure was in ex-
cess of 600 mm. of water. Examination of the fluid
revealed 6,040 white blood cells, 100 per cent of which
were polymorphonuclears. The smear showed numerous
gram-negative diplococci. Spinal fluid sugar was 28-
mg. per cent and the protein was 408-mg. per cent. The
hemogram revealed a hemoglobin of 14.7-gm. per cent,
white blood cells 25,000 with 93 per cent polvmorpho-
nuclears, 5 per cent lymphocytes, and 2 per cent mono-
cytes. Urinalysis was essentially normal. Admission
blood sugar was 1 19-mg. per cent, CO; combining power
was 23 mEq. per liter, and serum chloride was 99 mEq.
per liter. After completion of the spinal tap and prior
to the return of laboratory reports, the patient was begun
on a regimen which included intravenous fluids; sodium
sulfadiazine 200 mg. per kilogram per twenty-four hours,
Vi subcutaneously and 'A intravenously initially and then
subcutaneously only; and chloramphenicol 100 mg. per
kilogram per twenty-four hours.

Within one and one-half hours after admission the
patient’s blood pressure dropped abruptly to 100/55.
His skin became cool, and an alarming pallor developed.
His level of consciousness became more depressed. Hy-
drocortisone sodium succinate 150 mg. was given intra-
venously. Within an hour, his blood pressure was 120/75.
His skin became warm, and the color improved signifi-
cantly. Curiously, the previously described eruption had
disappeared. Upon report of the spinal fluid smear, the
patient’s treatment was altered to include aqueous crys-
talline penicillin, and the chloramphenicol therapy was
discontinued. Throughout the day, he remained restless
and semicomatose. His blood pressure stabilized at
120/70, and the eruption, which had disappeared, re-
appeared in the afternoon and remained for two to
three hours before vanishing permanently. He was given
an additional 25 mg. of cortisone intramuscularly later
that day. By evening, he was able to take fluids orally.
Twenty-four hours after admission, his rectal tempera-
ture was normal and, although moderately disoriented
and at times hallucinating, he was still able to take fluids
orallv without difficulty. Except for a transient episode
of gross hematuria, his subsequent course was most sat-
isfactory and uneventful. Penicillin and oral sulfonamide
therapy was continued for one week. On the second and
third days after admission, he was given 25 mg. of cor-
tisone every six hours. Subsequently, this dose was grad-
ually tapered over a ten-day period and discontinued.

Blood cultures taken on admission revealed numerous
colonies of gram-negative diplococci, which were charac-
teristic of Neisseria meningitidis. We feel that this was

FEBRUARY 1958

69

a case of meningococcic meningitis as well as meningo-
coccemia with probable early Waterhouse-Friderichsen
syndrome.

DISCUSSION

History. As late as 1938, it was candidly stated
that meningococcemia with the Waterhouse-
Friderichsen syndrome was 100 per cent fatal
and usually so within twenty-four hours.1 In
1940, with use of the sulfonamides,2 adrenal cor-
tical extract, and antimeningococcic serum, the
first cure of this syndrome was reported. During
the next 10 years, numerous attempts at therapy
incorporating use of adrenal cortical extract and,
later, desoxycorticosterone with sulfonamide and
penicillin were reported.3-6 Objective study of
the results of this type of steroid therapy left a
great deal of doubt as to the value of the steroids
in therapy of the Waterhouse-Friderichsen syn-
drome. In June 1950, a patient who had prev-
iously been given penicillin, sulfonamides, and
adrenal cortical extract and who appeared defi-
nitely moribund was given cortisone. He abrup-
tly improved and lived.7 This was the first re-
ported use of cortisone in the treatment of this
syndrome. Within six months, at least 2 other
cases8,9 were reported in the literature with en-
couraging results. Since that time, numerous
case reports10-13 have established that the use of
cortisone, hydrocortisone, and some of the newer
“meta” steroids are important additions to the
therapy of the Waterhouse-Friderichsen syn-
drome. In the case presented, intravenous rapid
acting hydrocortisone sodium succinate was used
initially with prompt and striking effect.

PATHOLOGY

It was thought for many years that gross, frank,
bilateral, adrenal hemorrhage causing acute adre-

REFERENCES

1. Christian, II. A.: The Waterhouse-Friderichsen Syndrome:

Fulminating Septicemia, Usually Meningococcic, with Ad-
cemia (Waterhouse-Friderichsen syndrome) with recovery:
(Supp.). New York: Oxford University Press, 1946, Vol. 5,

pt. 1, p. 106.

2. Carey, T. N.: Adrenal hemorrhage with purpura and septi-

cemia (Waterhouse Friderichsen syndrome) with recovery:
case report. Ann. Int. Med. 13:1740, 1940.

3. Appei.baum, E., and Nelson, J.: Sulfadiazine and its sodium
compound in treatment of meningococcic meningitis and men-
ingococcemia. Am. J. M. Sc. 207:492, 1944.

4. Bush, F. W., and Bailey, F. R.: Treatment of meningococcic
infections with especial reference to Waterhouse-Friderichsen
syndrome. Ann. Int. Med. 20:619, 1944.

5. Lohrey, R. C., and Toomey, J. A.: Epidemic meningitis and
meningococcemia treated with penicillin. J. Pediat. 28:86,
1946.

6. Sweet, L. K., Dowling, H. F., and Howell, M. J.: Acute
meningococcemia. J. Pediat. 30:438, 1947.

7. Nelson, J., and Goldstein, N.: Nature of Waterhouse-

Friderichsen syndrome. J.A.M.A. 146:1193, 1951.

8. Nelson, J., and Goldstein, N.: Nature of Waterhouse-

Friderichsen syndrome, (addend.). J.A.M.A. 146:1229, 1951.

9. Newman, L. R.: Waterhouse-Friderichsen syndrome; report

of a cure effected with cortisone. J.A.M.A. 146:1229, 1951.

10. Hodes, H. L., Moloshok, R. E., and Markowitz, M.: Ful-
minating meningococcemia treated with cortisone; use of
hlood eosinophil count as a guide to prognosis and treatment.

nal insufficiency was the etiology of the Water-
house-Friderichsen syndrome. This theory was
based on vascular damage secondary to a ful-
minating septicemia. In the early 1940’s, several
papers revealed numerous cases of the clinical,
classical Waterhouse-Friderichsen syndrome
which did not have the expected bilateral adre-
nal hemorrhages.1415 However, careful patho-
logic studies revealed that the hemorrhages mer-
ely represented the extreme late stages of adrenal
destruction, and, thus, when hemorrhage was
present, the primary pathologic picture was ob-
scured. These studies revealed that there was
degeneration of the cell cords of the zona fasci-
culata and neighboring adrenal cortical cells.16
When parenchymal destruction had taken place,
the highly vascular adrenal gland was engulfed
by hemorrhage as the perivascular structures
were destroyed. Experimental work has demon-
strated that this picture is not incompatible with
extreme stress, such as would be experienced
during fulminating septicemia.1718 Similar adre-
nal changes have been produced experimentally
as a “side reaction in studies of the localized
Shwartzman phenomenon.19 Microscopic studies
of the skin lesions have shown that they are
secondary to vascular dilatation and capillary
damage.

SUMMARY

A 13-year-old bov with meningococcic menin-
gitis and meningococcic septicemia with prob-
able early Waterhouse-Friderichsen syndrome
was successfully treated by use of hydrocorti-
sone, sulfonamides, and penicillin. The evolution
of the present therapeutic program is discussed
as well as some phvsiopathologic concepts of
this disease.

Pediatrics 10:138, 1952.

11. Breen, G. E., Emond, R. T. D., and Walley, R. V.: Wa-
terhouse-Friderichsen syndrome treated with cortisone; report
of 2 cases. Lancet 1:1140, 1952.

12. Griffin, J. W., Daeschner, C. W.: Meningococcal infec-

tions; with particular reference to fulminating meningococ-
cemia treated with cortisone and norepinephrine. J. Pediat.
45:264, 1954.

13. Baumann, F., Pearson, D. E., and Levin, M.: Adrenal cor-
tical steroids in management of a case of meningococcemia.
J. Pediat. 43:575, 1953.

14. Williams, 11. : Meningococcal infections in infancy and

childhood: II. Meningococcal septicemia with special reference
to adrenal apoplexy or the Waterhouse-Friderichsen syndrome.
M. J. Australia 2:557, 1942.

15. Schwarz, J.: Adrenal hemorrhages in meningococcal sepsis.

Arch. Path. 41:503, 1946.

16. Rich, A. R.: A peculiar type of adrenal cortical damage asso-
ciated with acute infections, and its possible relation to cir-
culatory collapse. Bull. Johns Hopkins Hosp. 74:1, 1944.

17. Zamcheck, N.: The normal human adrenal cortex and its

response to acute diseases. Am. J. Path. 23:877, 1947.

18. Selye, H., and Stone, H.: On the Experimental Morphology
of the Adrenal Cortex. Springfield, Illinois: Charles C Thomas.
1950.

19. Black-Schaffer, B., Hiehert, T. G., and Kerry, G. P.:
Experimental study of purpuric meningococcemia in relation
to Shwartzman phenomenon. Arch. Path. 43:28, 1947.

70

THE JOURNAL-LANCET

Will E. Donahoe, M.D.

Phys man , Educator, mid Humanitarian

By j. ARTHUR MYERS, M.D.

Fok more than a third of a century, no meeting
of pediatrists or public health workers, either
local or national, has been complete without Will
Donahoe’s presence. It has not been just from his
participation in formal programs but from personal
conversations with him in hotel rooms and lobbies,
in assembly halls immediately before and after meet-
ings, during breaks to visit exhibits, and so forth,
that so many physicians have learned so much from
him.

Aside from periods of schooling at St. Thomas
College, St. Paul, and the University of Illinois, his
entire life has been lived in Sioux Falls, South Da-
kota, where he was born May 18, 1886, when that
area was still Dakota Territory. After completing
an internship, he entered general practice in Sioux
Falls in 1913. There he saw the almost unlimited
possibilities of increasing human longevity through
treatment and prevention of diseases which were
incapacitating, maiming, and crippling large num-
bers of children. He also saw the opportunity afford-
ed him of informing parents and the public in gen-
eral of methods bv which children could be pro-
tected against many of the conditions that were de-
stroying them. Therefore, he decided to devote the
remainder of his professional life to that cause. In
1919, he went to the University of Iowa for post-
graduate work in pediatrics. He then spent five
months divided between clinics and ward rounds
under Doctors Abt and Brenneman in Chicago and
Doctor Sedgewick of the University of Minnesota,
before returning to Sioux Falls where he has since
confined his practice to pediatrics and public health.

Much of the time that could be snatched from the
demands made upon him in practice was devoted
to reading the best medical journals and books in
his field. This, together with attendance at conven-
tions, kept him abreast of the latest developments
and far ahead of most physicians.

He realized that the best time to transmit infor-
mation concerning health was when persons were
personally interested. Therefore, he has devoted a
great deal of time to individual patients and their
families, which inspired their confidence in him.

He has always enjoyed community endearment
as he was ever ready to devote whatever time and
energy any community health problem required. F’or
example, in 1920, he introduced into the area he
served the first immunization program against diph-
theria. The same year he established the first public
clinic in the state for ill and well children and served
as school physician from 1920 to 1936— for 11 years
without compensation.

Beginning in 1925 and continuing until 1936, he
was the health officer of Sioux Falls on a part-time
basis. Since this office was the official health agency,
a magnificent opportunity was provided to make
recommendations, to introduce new procedures, and
to support others already being utilized. In fact,
during this period. Doctor Donahoe contributed sig-
nificantly to the entire state program, not only
among physicians but also with other groups, includ-
ing educators and the public. Better sanitation laws
were enacted pertaining to such items as dairy prod-
ucts. He supported the veterinarians in their cam-
paign to eradicate tuberculosis from the cattle herds.

FEBRUARY 1958

71

He instituted tuberculin testing of school children.

As he retired from the health officership of Sioux
Falls, he became superintendent of the Board of
Health of his entire (Minnehaha) county. He per-
sonally checked for three successive years the 100
rural schools of the county. This had never been
done, and the sanitary conditions and physical facili-
ties were most deplorable. More than 60 per cent
of the drinking water was proved unsafe. Correc-
tions were obtained during this period in practically
every instance. During these three years, the chil-
dren were tuberculin tested and examined and re-
ferred to their own physicians for immunizations and
corrections. The promised payment by the county
commissioners was denied and the services, there-
fore, were discontinued. Recent survey of the schools
by the press showed that they had again dropped
to their former state.

He led the way in the organization of the South
Dakota State Health Officer’s Association. While
president of this organization, he combined it with
the Tuberculosis Society under the name South Da-
kota Health and Tuberculosis Association.

He formulated the idea of greater political and
economic strength in a union of the inter-allied
groups in South Dakota in 1933. This brought all
6 groups together in Sioux Falls in 1936 for their
annual meetings and general sessions. Some 1,100
persons attended the closing banquet. This was the
first group of so manv inter-allied bodies in the coun-
try. Communications were received from the New
York Society, and official representations attended
from Illinois and Iowa State Medical Associations.

He has been a prominent worker with the Red
Cross and the Salvation Army, having served on
their boards. At present, he is a member of the
Executive Board of the Volunteers of America.

The vear after he entered general practice, he
organized the first Boy Scout troup in Sioux Falls.
His interest in this organization has continued
throughout the years and, in 1938, he received the
Silver Beaver award of the Bov Scouts of America.

During World War I, he served in the United
States Medical Corps and was Commander of the
United States Public Health Service of Armed Forces
Reserve from 1944 to 1954. He is a charter mem-
ber of the American Legion.

Doctor Donahoe is a member of the Sioux Falls
Chamber of Commerce, Rotary, Elks, Walton
League, and the Minnehaha Country Club. He is
past State Master of the Fourth Degree Knights of
Columbus.

His popularity among physicians is evidenced by
his election to three successive terms as president of
the Seventh District Medical Society in 1928, 1929,
and 1930. He served on the council of the State
Medical Association from 1930 until he retired as
chairman in 1945.

He has long been a member of the active staff of
the Sioux Valley and McLennan hospitals, as well as
attending physician to the South Dakota State Chil-
dren’s Home, Presentation Home, and Lutheran
Home House of Mercy. He organized the Guild of
Catholic physicians and has since been its president.

Nationally and internationally he is a fellow of
the American Medical Association, a diplomate of
the American Board of Pediatrics, a fellow in the
Academy of Pediatrics, a fellow in the Academy of
Internal Medicine, as well as past fellow of the
American Association of School Physicians and the
American Public Health Association.

He has long been active in the Northwestern Pe-
diatric Society and the Sioux Valley Medical Society,
which he has served as president.

He is co-chairman of the Inter-Hospital Commit-
tee in Sioux Falls, Community Physicians Disaster
Committee, and chairman of the American Academy
of Pediatrics.

It is difficult to comprehend how one physician
could in a lifetime serve so many so well and in
so many ways. In leading and directing these activ-
ities, Doctor Donahoe has exhibited unusual ability
in avoiding jealousy and enmity, which so long ago
caused it truly to be said that “The prophet is not
without honor save in his own country.” In 1952,
the Cosmopolitan and Civic Clubs of Sioux Falls
conferred upon him the Distinguished Community
Service Award based on the theme of charity and
children.

In 1957, the South Dakota State Medical Associa-
tion conferred upon him its Distinguished Service
Award for practice of medicine and promotion of
public health.0

In addition to the large volume of informal teach-
ing done throughout his professional career of 47
years, he is also clinical professor of pediatrics at
the Medical School of the University of South Da-
kota.

This sketch, which should be expanded to a large
volume, must not close without an expression of
personal appreciation. Over a long period of years,
he has been a true friend. Our meetings at vari-
ous national conventions, as well as in South Dakota
and Minnesota have, without exception, been most
helpful and inspiring. His kindly spirit, his calm
and considered judgment, lack of selfishness, his
great store of knowledge, his numerous accomplish-
ments, and his goodness in every way have made
each of our many associations most pleasant and
profitable. His life is one to be emulated by all who
strive to become truly great American citizens.

“This citation was published in full in the July issue of
the South Dakota Journal of Medicine and Pharmacy.
With consent of the editor, I have drawn freely from
this citation. The South Dakota State Medical Associa-
tion kindly provided the photograph.

72

THE JOURNAL-LANCET

IPRONIAZID

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Original Research in
Medicine and Chemistry

21A

Progress in Radiobiology. Proceed-
ings of the fourth international
Conference on Radiobiology held
in Cambridge, August 14 to 17,
1955. Edited by Joseph S. Mit-
chell, Barbara E. Holmes, and
Cyril L. Smith, 1956. Spring-
field, Illinois: Charles C Thomas,
557 pages. $12.75.

A great variety of research topics
and interesting discussions by dele-
gates are presented in this book.
These factors, together with the
available bibliographies, provide the
reader with an excellent reference
work in radiobiology. This account
is of particular value to the investi-
gator working in America because of
the wealth of information coming
from research laboratories in other
countries.

This account of current trends in
radiobiologic research emphasizes
the importance of fundamental re-
search on the effects of ionizing ra-
diations on biologic systems as a
basis for improved clinical applica-
tions. Furthermore, it serves to point
out the need for investigators trained
in various disciplines in order to
carry out an effective research pro-
gram encompassing the many facets
of radiobiology.

M. K. Loken, Ph.D.

•

The Merck Manual of Diagnosis
and Therapy , ed. 9. Editorial
board: Charles E. Lyght, M.D.,
editor; William P. Boger, M.D.;
George A. Carden, M.D.; Augus-
tus Gibson, M.D.; and Dickin-
son W. Richards, M.D., 1957.
Railway, New Jersey: Merck &
Co., Inc., 1,870 pages, illustrated.
Cloth $6.75, deluxe $9.00.

This popular and comprehensive
book has been thoroughly revised,
and many portions have been com-
pletely rewritten. Additional excel-
lent and extremely useful plates
have been included, which, for ex-
ample, illustrate the technic of intra-
articular injection, tracheotomy, lum-
bar puncture, and gastrointestinal
suction siphonage procedures. Con-
tributing to its value are hundreds
of prescriptions, 63 tables, and spe-
cial sections devoted to the enhance-
ment of medical diagnosis and treat-
ment. The index has been consid-
erably expanded and more liberally
cross-referenced than before.

Although this edition contains
over 300 pages more than the last,
the use of extra thin paper has pre-
served the handy format of the
book.

The Merck Manual continues to

BOOK

RFVTFWS

.A A T .iBki. mW «4 f "

be an outstandingly accurate and
up-to-date reference book, giving
practical assistance to all those en-
gaged in the practice of medicine
and in the allied professions.

J. A. Myers, M.D.

•

Physio pathology of the Reticulo-
endothelial System, edited under
direction of B. N. Halpern, 1957.
Springfield, Illinois: Charles C

Thomas. $9.00.

Seventeen authoritative articles on
the reticulo-endothelial system and/
or related problems constitute the
contents of this volume, which sum-
marizes the proceedings of a sym-
posium organized bv the Council
for International Organizations of
Medical Sciences and the Unitarian
Service Committee under the able
direction of B. N. Halpern of Paris.

It is well over four decades ago
since Aschoff crystallized the con-
cept of the RES on the basis of
studies with colloidal suspensions of
vital dyes. Since his pioneering
work, the readily identifiable prop-
erty of phagocytosis is known to be
related to the cells derived from the
diffuse reticulum and the lining vas-
cular epithelium of connective tis-
sues (the RES). These phagocytic
cells are now regarded as a third
systemic line of defense, which
comes into play over and above the
first two defenses, namely, those at
the site of entry of an invader and
those at the site of the regional
lymph nodes. In addition to phago-
cytic functions, certain metabolic and
humoral defense functions are also
related to the RES. These cells are
able to absorb ehylomicra formed
by lipids and exogenous cholesterol
and participate in iron metabolism
by storing it or by controlling its
exchanges with humoral factors of
iron transport. The more important
known roles of the RES concern,
however, the handling of toxins and
particularly endotoxins, but opinions
are still divided on the exact mech-
anisms and role of this defense func-
tion of the RES. The title of the
book is, perhaps, misleading; patho-

physiologic aspects of the RES rath- U
er than physiopathologic considera- j
tions are in the foreground. This 1
may be more than only a matter of ,
semantics, since it is the physiology
of the RES which will call for con- j
siderable additional work in the fu-
ture. The status quo of our knowl-
edge in this field is hardly surpris- J
ing. The RES originated as a con-
cept primarily from morphologic
considerations. It has gained in- |
creasing importance from contribu- i
tions in many other fields ranging
from physical chemistry to bacteri-
ology and immunology. The meth-
odology available for physiologic il
studies on the RES is discussed in i
detail in this volume, which is rec-
ommended primarily to investigators I
in the basic and applied medical
sciences.

Franz Halberg, M.D. i

*

Lupus Nephritis, by Robert C.
Muehrcke, Robert M. Kark,
Conrad L. Pirani, and Victor
E. Pollack, 1957. Baltimore:
Williams & Wilkins Co., 133'
pages, 13 pages of references, 11
chapters. $3.00.

This book is a classical, detailed, '
clinical, and pathologic studv of
lupus nephritis based on renal bi-
opsies. The authors’ experiences with
33 patients provide the background.
The diagnosis, prognosis, and treat- '
ment are vividly discussed. The il-
lustrations of the histologic changes
are excellent. The literature is ex-
tensively reviewed. The text is very
well written, and there is a mini-
mum of typographical errors. The
bibliography is comprehensive. The
paper is of excellent quality. This
text would be a valuable addition
to the library of any physician.

M. P. Reiser, M.D.
o

The Recurrent Laryngeal Nerves in
Thyroid Surgery, by William H.
Rustad, M.D., 1956. Springfield,
Illinois: Charles C Thomas. $4.50.

This is an excellent anatomic study
of the recurrent laryngeal nerves,
which presents a practical applica-
tion to the thyroid surgeon. The
author’s purpose is to call attention
to the recent recognition that many
of the postoperative derangements
of laryngeal function are due to
damage of the branches of the re-
current laryngeal nerve, hitherto
generally regarded as a single nerve.

The anatomy of the larynx is ac
curately reviewed because the right
and left recurrent laryngeal nerve
(Continued on page 24A)i

ht

22A

When

a A

the bronchial tree
has too much “bark”

make cough MORE PRODUCTIVE,
LESS DESTRUCTIVE

‘‘Significantly superior”2 cough therapy for ‘‘markedly”
reducing the severity and frequency of coughing,1 for
increasing respiratory tract fluid,1 for making sputum
easier to raise,3 and for relieving respiratory discomfort.4

A. H. ROBINS CO., INC., RICHMOND 20, VIRGINIA

Ethical Pharmaceuticals of Merit since 1878

References:

1. Blanchard, K., and Ford, R. A.:
Clin. Med. 3:961, 1956. 2. Cass, L. J.,
and Frederik, W. S.: 2:844, 1951.
3. Hayes, R. W., and Jacobs, L. S.:
Dis. Chest 30:441, 1956. 4. Schwartz,
E., Levin, L., Leibowitz, H., and
McGinn, J. P.: Am. Pract. & Digest
Treat. 7:585, 1956.

ROBITUSSIN

Glyceryl guaiacolate 100 mg. and desoxyephedrine hydrochloride 1 mg. per 5 cc.

ROBITUSSIN’ A-C

Robitussm with Antihistamine and Codeine: Same formula as Robitussin, plus
prophenpyridamine maleate 7.5 mg. and codeine phosphate 10 mg. per 5 cc. (Exempt narcotic)

V s' '

BOOK REVIEWS

(Continued from page 22A)
supplies all the muscles of the lar-
ynx except the cricothyroid. The
cricothyroid muscle receives its in-
nervation from the external branch
of the superior laryngeal nerve. The
author’s investigations have estab-
lished that the recurrent laryngeal
nerve frequently divides into two
branches, less often into four to six
branches, all entering the larynx.

In making a clinical application of
these facts, the author states that
“the recurrent laryngeal nerve,
whether as a main single trunk or
whether broken up into a variable
number of component branches, has
been seen to enter into many di-
verse and completely unpredictable
branching patterns.” He further
states that there are no constant dif-
ferences in the relationship between
the inferior thyroid artery and the
recurrent nerve on the right and left
side. The author from his study,
embryologically states emphatically
that it is impossible for the recur-
rent laryngeal nerve to enter the
thyroid gland parenchyma. He fur-
ther concludes that “because of the
branching of the nerve, it is not
practical, where the primary mission
of the operation is to remove the
gland, to isolate the recurrent nerve
completely, since the operator may

be deceived by dissecting out only
one branch.” In a further clinical
suggestion, he recommends the ap-
plication of ligatures to the inferior
thyroid artery lateral to the tracheo-
esophageal groove to avoid injury to
the nerve. Pre- and postoperative
laryngoscopy are urged. Numerous
excellent illustrations of the anatomy
of the recurrent laryngeal nerves are
presented.

This book should be in the pos-
session of every surgeon engaged in
thyroid surgery.

Martin Nordlano, M.D.

•

Hypertension, by Irvine H. Page,

M.D., ed. 2, 1956. Springfield, Il-
linois: Charles C Thomas. $3.00.
This manual on hypertension, writ-
ten for patients, for them amounts to
a textbook of sound information. An
outstanding student of and authority
on hypertension discusses the subject
and explains what it is, why the phy-
sician has performed the various ex-
aminations, and what can be done
about the condition. While the best
transfer of information to the patient
is given by the physician who has
personally examined him at not in-
frequent intervals, the patient’s ac-
cess to such a book will supplement
his physician’s viewpoint. This man-
ual may well indeed be recommend-

ed for the inquisitive and curious
person. The paragraphs on Cultiva-
tion of the Soul may profitably be
read by physician and patient alike.

C. A. McKinlay, M.D.

•

Natural Childbirth, by H. B. Atlee,
M.D., 1956. Springfield, Illinois:
Charles C Thomas, 79 paces.
$2.75.

This is a small volume as are the
others of the American Lecture se-
ries. The author presents his own
concepts of a philosophic approach
to pregnancy and, particularly, to
labor. He describes his own technic
for natural childbirth together with
the organization of the prenatal
teaching classes and their content.
There is a chapter dealing with the
physical arrangement of a lying-in
unit for use in this sort of an ap-
proach to labor.

It is a short presentation but con-
tains a great deal of what appeals to
the reviewer as the wisdom of care-
ful observation and long experience.
Some of his conclusions are stated
in pungent terms which will remain
in the mind of the reader. One could
hope that everyone doing obstetrics
would read the essay and ponder
over it.

John L. McKelvey, M.D.

News Briefs . . .

North Dakota

The new clinic at Northwood, North Dakota, is now
completed. An addition to the Northwood Deaconess
Hospital, the building is of modern design and well
equipped to meet a wide range of medical and surgical
needs.

e ooo

Dr. L. G. Pray of Fargo has been elected president of
the First District Medical Society. Other officers are:
Dr. A. L. Klein, Fargo, vice president; and Dr. Frank
M. Melton, Fargo, secretary-treasurer. Delegates to the
North Dakota State Medical Society are: Dr. Arthur C.
Burt, Dr. Frank M. Melton, Dr. W. L. Macaulay, Dr.
F. A. DeCesare, Dr. John S. Gillam, all of Fargo; and
Dr. E. ]. Beithon, Wahpeton. Alternates are: Dr. D. G.
Jaehning, Wahpeton; Dr. L. E. Wold, Dr. |. F. Hough-
ton, Dr. J. F. Schneider, Dr. B. F. Amidon, and Dr.
Henry A. Norum, all of Fargo. Dr. Earl M. Haugrud,
Fargo, was elected censor.

O O O O

Dr. Phillip O. Dahl has been elected president of the
medical staff at St. Alexius Hospital in Bismarck. He
succeeds Dr. P. Roy Gregware, who will continue to
serve on the executive committee of the staff in his
capacity as past president. Other officers elected to serve

during 1958 include: Dr. Paul L. Johnson, president-
elect; Dr. Olav V. Lindelow, secretary; and Dr. Robert
W. Henderson, member-at-large.

o o o o

Dr. Ralph D. Weible, who has been with the Dakota
Clinic in Fargo since 1940, except for four years with
the Army Medical Corps during World War II, has been
elected president of the St. John’s Hospital staff. Other
new officers are: Dr. Lee A. Christoferson, vice presi-
dent, and Dr. Richard |. Zauner, secretary-treasurer. New
members of the advisory board are Dr. Zauner and Dr.
|. F. Schneider. Holdover members are Dr. W. B. Arm-
strong and Dr. O. A. Sedlak.

o o o o

Dr. Clarence Davis, Jr., a Watford City physician, has
been appointed district deputy health officer for Mc-
Kenzie Countv.

o o o o

Dr. Robert Ivers, who recently completed his intern-
ship and residency at St. Luke’s Hospital, Fargo, has
been granted a fellowship in neurology at the Mayo
Clinic. Dr. Ivers left for Rochester on December 27.

o o o o

Dr. Gilbert J. Guscott and Dr. John L. Magness,
both natives of Ohio, have become associated with the
Dakota Clinic in Fargo. Dr. Guscott is head of the De-
partment of Physical Therapy, and Dr. Magness is in
the Department of Internal Medicine.

(Continued on page 26A)

24A

SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

Surgery in Heart Disease

JOHN FRANCIS BRIGGS, M.D.
St. Paul, Minnesota

Surgeons have become important members of
the team in the diagnosis and treatment of
heart disease. As a result of their efforts, great
contributions to cardiology have been made and
many new treatments have been devised, which
augment the medical care of the patient suffer-
ing from heart disease. Some surgical procedures
are curative and others palliative. The following
cardiovascular diseases may be benefited by sur-
gery:

the aorta

Patent ductus arteriosus is essentially an arterio-
venous fistula. A machinery-hum murmur heard
over the pulmonary artery area to the left of the
sternum establishes the diagnosis. In addition,
there is a wide pulse pressure and usually a
characteristic x-ray picture. The electrocardio-
gram is of no value in a patent ductus arteriosus.
Treatment is surgical.

The “ aorticopulmonanj window” syndrome.
The physical findings are the same as those in
a patent ductus, but the machinery-hum murmur
may be heard only at the lower end of the ster-
num. Many times the diagnosis is not estab-
lished until surgical exploration is carried out.
The surgeon attempts to find a patent ductus and,
not finding it, discovers the communication be-
tween the aorta and the pulmonary artery. An-

john f. briggs is associate professor of clinical medi-
I cine at the University of Minnesota.

Paper presented before the North Dakota State
Medical Association at Fargo, North Dakota, May
27, 1957.

giograms may be of value in the diagnosis. Sur-
gerv, when possible, is curative.

Coarctation of the aorta is diagnosed by find-
ing hypertension in the upper extremity and hy-
potension in the lower extremity. The physical
findings are negligible, but a systolic murmur
may be heard over the aortic area, and, when
the lesion is associated with a bicuspid aortic
valve, a diastolic murmur may also be present.
The diagnosis can be made clinically by feeling
the radial artery while, at the same time, palpat-
ing the femoral artery. In coarctation of the
aorta, the femoral pulsations are diminished or
absent. The x-ray film is often of no value, but
scalloping of the ribs may be present. The elec-
trocardiogram may be normal or show a left-
axis deviation. Angiograms may indicate the
degree of stricture as well as the location of
the stricture in the aorta. Surgery is curative.

Arteriovenous fistulae, both congenital and ac-
quired, can be cured by surgery. Thrombosis of
the aorta is amenable to surgery as are arterial
embolic phenomena.

Abnormalities of the vascular rings may pro-
duce either dysphasia or stridulous respiration.
The diagnosis should be suspected in any new-
born who has difficulty in swallowing or who
has a stridulous type of respiration. Once the
diagnosis is established, the treatment consists
of ligation and severance of the offending blood
vessel.

Aneurysms of the aorta may be congenital or
acquired. Previously, almost all acquired aneu-
rysms were luetic in origin, but todav they rep-
resent an arteriosclerotic process. The diagnosis

may he made accidentally by finding the pulsat-
ing mass on physical examination or by seeing
a mass on the x-ray film or by fluoroscopy. Occa-
sionally, the first knowledge of the existence of
the aneurysm occurs as the result of a vascular
crisis after rupture or dissection of the aneurysm.
The shock picture, drop in blood pressure, and
the altered pulsation of the affected blood vessels
make the diagnosis easy. Operation is indicated
as an emergency procedure. It is my opinion
that all patients with aneurysm of the aorta
should undergo surgical treatment if feasible.

HEART

In a review of the lesions that may be amenable
to surgical treatment, we shall start with those
that are within the heart itself.

Septal defects. Atrial septal defects are not
uncommon. The diagnosis may be suspected
because of the gracile habitus of the patient.
Cyanosis and/or clubbing may or may not be
present. There is usually a systolic murmur over
the base of the heart, and there may be an asso-
ciated diastolic murmur. Tbe roentgenogram is
rather characteristic in that it shows an enlarge-
ment in the conus area with dancing pulmonary
blood vessels on fluoroscopy. The electrocardio-
gram may be normal or reveal a right-axis devia-
tion. Cardiac catheterization as well as angio-
cardiography are of value in the diagnosis and
management of these patients. I believe that
surgery is indicated in all of these cases.

Ventricular septal defects may vary in size
from minute openings to complete absence of
the ventricular wall. The physical findings reveal
a loud blowing systolic murmur over the middle
of the sternum opposite the third and fourth
interspaces. In addition, a systolic thrill is found.
The heart may be normal in size. Roentgeno-
grams are of no importance in diagnosis, and the
electrocardiogram is seldom an aid in this re-
spect. Cardiac catheterization and angiocardiog-
raphy, as well as other laboratory procedures, are
of great value in both the diagnosis and in plan-
ning treatment. I believe that these patients do
not require surgical treatment unless there is
evidence of cardiac embarrassment.

A septal defect can occur by a perforation of
the septum complicating acute myocardial in-
farction. The symptoms are sudden, severe heart
failure complicating the course of the myocardial
infarction. The signs are the same as in the con-
genital defect. Surgery should be attempted.

Tetralogy of Fallot. In this condition, there is
pulmonary stenosis with an interventricular sep-
tal defect, various degrees of transposition of the
great vessels, and enlargement of the right side

of the heart. These patients are the classical
“blue baby” individuals. Cyanosis is outstanding,
and the fingers and toes are usually clubbed. A
blowing systolic murmur is heard over the pul-
monary area. The roentgenogram shows enlarge-
ment of the right heart, which is verified by the
fluoroscopic examination. The electrocardiogram
reveals a right -axis deviation with or without
strain. In such cases, cardiac catheterization and
angiocardiography may be of great value in as-
sisting in the diagnosis. Surgery is always indi-
cated in these patients.

Anomalous venous return is a condition in
w hich the venous return to the right side of the
heart is abnormal. When recognized, surgery
should be attempted.

Valvular defects — the aortic valve. Aortic
stenosis may be congenital or acquired. If con-
genital, it may be valvular in origin or a sub-
aortic stenosis. In subaortic stenosis, a mem-
brane partially closes off the lumen of the aorta.
Acquired stenosis is almost alwavs rheumatic in
origin, and, in later life, the lesion becomes cal-
cified, producing tbe calcific nodular valve de-
fect. A sytolic murmur is heard over the aortic
area, which is transmitted into the vessels of the
neck and apex. Occasionally, a diastolic murmur
may be present. The blood pressure varies, but
seldom is the diastolic pressure below normal.
A systolic thrill may be present, and the second
sound may be decreased or absent. The roent-
genogram shows enlargement of the left side of
the heart, and calcification may be demonstrated
in the aortic valve. The fluoroscopic examina-
tion adds little to the film studies. The electro-
cardiogram shows left-axis deviation with or
without left heart strain. I feel that the present
treatment of aortic stenosis is such that surgerv
is not indicated unless the patient has ( 1 ) signs
of heart failure, (2) attacks of syncope, or (3)
anginal seizures. The surgical treatment of the
congenital defect, I believe, is indicated.

Aortic insuffciencij . At one time, aortic insuf-
ficiency was almost always luetic in origin, but
today it is almost always rheumatic. The diag-
nosis is made by finding a diastolic murmur in
the aortic area. The diastolic blood pressure
drops, and a wide pulse pressure is present. A-ra\
examination reveals an enlargement of the left
side of the heart. Fluoroscopic examination adds
little. The electrocardiogram reveals left-axis
deviation with or without left heart strain. Sur-
gery in these patients is indicated when there is
(1) congestive heart failure, (2) attacks of syn-
cope, and (3) anginal seizures. The introduc-
tion of a plastic valve decreases the degree of
regurgitation and benefits the patient.

74

THE JOURNAL-LANCET

The pulmonary valve — pulmonary stenosis.
Pulmonary stenosis is essentially a congenital
defect. It may be valvular or infundibular in
type. A blowing systolic murmur is heard over
the pulmonary area, which is frequently associ-
ated with a systolic thrill. The second pulmonic
sound may be diminished or absent. The chest
x-ray reveals an absence or decrease in the size
of the conus area. Fluoroscopic examination re-
veals not only a decrease in this area but a de-
crease in vascularization of the lungs. The elec-
trocardiogram usually shows a right-axis devia-
tion with or without right heart strain. This
defect may be isolated or found in association
with other congenital defects. Cardiac catheter-
ization and angiocardiography are invaluable in
the diagnosis and treatment of this condition.
I believe that all of these patients should under-
go surgery.

Mitral stenosis. Mitral stenosis may be con-
genital in origin, but the greatest number of
cases are due to rheumatic fever. The problem
in diagnosis is to be certain that it is a “tight
mitral stenosis.” I believe that the diagnosis of
a “tight mitral valve” can be made clinically.
The following criteria are necessary to establish
the diagnosis:

1. The presence of either a presystolic or a
mid-diastolic murmur at the apex. A harsh mur-
mur late in systole may also indicate a “tight
mitral valve.”

2. The first sound should be accentuated, the
second pulmonic sound should be duplicated,
and/or a diastolic murmur should be heard over
the pulmonic area.

3. The heart should be normal in size, and
this can be confirmed by fluoroscopic x-ray ex-
amination. In addition, the esophogram should
be positive. The electrocardiogram should re-
veal a right-axis deviation with or without right
heart strain.

Opinion differs as to when surgery is indicated
in the treatment of the mitral valve defect. Ob-
viously, the treatment is directed toward reliev-
ing the pulmonarv hypertension. I feel that sur-
gery is not indicated in mitral stenosis unless
there is (1) clinical evidence of pulmonary hy-
pertension, and/or (2) if medical treatment fails
to control the cardiac difficulty. Surgery is al-
ways indicated in embolization. We must re-
member that a commissurotomy may be only
temporary, and the patient may again come to
surgery at a later date should the valve re-
stenose. Surgery in mitral heart disease is con-
traindicated when the mitral insufficiency is the
predominant lesion. This may be diagnosed by
finding a loud systolic murmur at the apex. The

second pulmonic sound is not accentuated. The
left ventricle is enlarged clinically. The roent-
genogram reveals enlargement of the left ven-
tricle, and this can be confirmed by fluoroscopic
examination. An electrocardiogram shows left-
axis deviation with or without left heart strain.
The presence ol active rheumatic carditis, sub-
acute bacterial endocarditis, or other significant
cardiac lesions also contraindicate surgical in-
tervention.

Mitral insufficiency may be diagnosed as out-
lined previously. The value of surgical treatment
is questionable.

Tricuspid stenosis is usually congenital in ori-
gin and suggests the tetralogy of Fallot syn-
drome with the exception of the fact that the
electrocardiogram usually shows a left-axis de-
viation with left heart strain in contradistinction
to the right-axis deviation with heart strain. In
these cases, surgery should be attempted.

Coronary artery disease. A number of meth-
ods have been suggested for the surgical treat-
ment of this condition. Attempts to relieve the
pain have been made by paravertebral injections
of alcohol, Novocain, and the like. Cervical sym-
pathectomy has been suggested. Although these
procedures may alter the degree of pain, they,
in turn, however, are not without danger and
are not recommended. Direct attempts to revas-
cularize the heart have been many. It could
serve no purpose to list all these methods, for
it is my opinion that, at this time, no surgical
procedure is of value in the treatment of coro-
nary heart disease.

The Pericardium. Acute pericarditis may be
associated with the rapid accumulation of fluid
in the pericardial sac, producing a cardiac tam-
ponade. Depending upon the etiology of the
pericarditis, the fluid may be serous, purulent,
or a combination of both. As a result of the
rapid accumulation of fluid, the cardiac output
is decreased. There is a decrease in venous re-
turn to the heart. The venous pressure rises
rapidly, and the pulse becomes weak. Physical
examination reveals that the jugular veins are
greatly distended, the heart is silent, and the
cardiac dullness is increased. The electrocardio-
gram may show changes of pericarditis. The
roentgenogram shows a rather typical pear-
shaped type of heart, and fluoroscopic examina-
tion usually reveals absence of demonstrable pul-
sations. The removal of fluid is imperative. It
may be removed by puncture or by surgical
drainage. Treatment should then be directed
toward the cause of the pericarditis.

Chronic constrictive pericarditis. In this con-
dition, the heart is encased in a fibrous mass.

MARCH 1958

75

I he insidious onset of the disease makes diag-
nosis difficult. The patient is suggestive of an
individual with cirrhosis of the liver with the
exception that there is a pronounced increase
in the venous pressure. The physical findings
are those of an individual with congestive heart
failure, and the veins in the neck are markedly
distended. The heart is silent and usually small
and fixed in position. The x-ray examination re-
veals the small heart, and, occasionally, calcifica-
tion may be seen in the pericardium. The fluoro-
scopic examination and kymographic examina-
tion emphasize the decreased pulsations. Car-
diac catheterization often is of value because a
characteristic pressure curve may be present.
The electrocardiogram may suggest the diagnosis
because of the altered ST and T segments as well
as low voltage. Once the diagnosis is made, sur-
gery is indicated.

1 he heart may be injured by direct or indirect
trauma to the chest wall. One should always
be alert to the possibility of a laceration of the
heart, hemopericardium, or laceration of a valve.
Surgery should be immediate if indicated.

Tumors of the heart should be removed when
possible.

CONCLUSION

Many surgical procedures are available which
are of benefit to the cardiac patient. These pro-
cedures may be curative in some instances and
palliative in others. We must always be alert to
the benefits that may result from surgical inter-
vention. It is suggested that in the treatment
of heart disease, we must consider in each case
whether the patient is one in whom surgery can
complement or supplement our medical treat-
ment.

Cholesterosis of the gallbladder is caused by an aberration in cholesterol
metabolism. Lipoid material is most abundant in the villi of the mucosa but
may also be found in other layers of the gallbladder.

Abdominal pain, the most prominent svmptom, may be localized in the
right upper quadrant, the periumbilical region, or the epigastrium and is re-
ferred to the back or shoulder in about half of patients. Other symptoms in-
clude gaseous eructation, flatulence, nausea, vomiting, and intolerance to fried
and fattv food. Women are more frequently affected than men.

Cholecystitis is sometimes associated with cholesterosis; however, the latter
condition may cause symptoms without inflammation of the gallbladder.

Because cholesterosis does not produce fibrosis or impair concentration and
emptying, roentgenographic examination shows no abnormality in about one-
half of patients. When choleevstograms are normal but symptoms are charac-
teristic of gallbladder disease, duodenal drainage should be done. If micro-
scopic study shows cholesterol crystals in the B bile so obtained, the patient
has cholesterosis.

Removal of the diseased gallbladder will usually relieve symptoms. How-
ever, cholecystectomy should not be performed if the diagnosis cannot be
definitely established.

William F. Mitty, Jr., M.D., and Louis M. Rousselot, M.D., St. Vincent’s Hospital and New
York University, New York City. Gastroenterology 32:910-916, 1957.

76

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Acute Nonspecific Pericarditis

JAMES H. KELLY, M.D.
Minneapolis, Minnesota

Acute fibrinous pericarditis is an inflamma-
tion of the pericardium associated with the
formation of a fibrinous exudate on the pericar-
dial surfaces. The inflammatory process may sub-
side or progress and may be complicated by a
serous, serosanguineous, or purulent exudate.

Acute pericarditis may be classified into the
following groups:

1. Acute nonspecific pericarditis.

2. Infectious pericarditis,

a. Pyogenic pericarditis,

b. Tuberculous pericarditis,

c. Mycotic pericarditis,

d. Parasitic pericarditis.

3. Pericarditis occurring as a manifestation of
of the “collagen diseases.”

a. Rheumatic pericarditis,
b. Pericarditis accompanying rheumatoid
arthritis.

e. Pericarditis of disseminated lupus ery-
thematosus.

d. Pericarditis occurring in periarteritis no-
dosa.

4. Uremic pericarditis.

5. Pericarditis secondary to myocardial infarc-
tion.

6. Pericarditis due to neoplasm.

7. Traumatic pericarditis.

8. Rare forms of pericarditis of uncertain eti-
ology.1

This paper will deal with acute nonspecific
pericarditis, which is the collective name for
cases of acute pericarditis in which no systemic
or local causal agent can be demonstrated. It
is typically characterized bv antecedent infec-
tion of the respiratory tract, chest pain, fever,
tachycardia, pericardial friction rub, electro-
cardiographic changes, and a tendency toward
both pericardial and pleural effusion. It has been
referred to as idiopathic, epidemic, primary, non-
rheumatic, benign, relapsing, cryptic, fugitive,
and recurring pericarditis.2

This disease entity was probably first des-
cribed by Hodges in 1854. 3 In 1942, Barnes and
Burchell,4 of the Mayo Clinic, reported 14 cases

james h. kelly is a resident in internal medicine at
Veterans Administration Hospital, Minneapolis.

of acute nonspecific pericarditis simulating myo-
cardial infarction. Since that time, numerous
reports describing this disease have appeared in
the literature. This is probably due to its recog-
nition as a specific entity rather than to any act-
ual increase in the frequency of acute non-
specific pericarditis. It is a relatively rare dis-
ease. Only 1 reported series has included more
than 30 cases.5 The true incidence of this dis-
ease is difficult to ascertain. Diligent search for
specific etiology should be carried out in each
case. Its occurrence as a cause of acute pericar-
ditis has been reported to vary from 10 per cent11
to 33 per cent.7 These percentages can be ex-
pected to vary considerably, depending upon
the age, racial and socioeconomic status of the
group studied, as well as the physician’s aware-
ness of acute nonspecific pericarditis as a definite
entity.

DIAGNOSIS

Acute nonspecific pericarditis has generally been
thought to be a disease of young adults. How-
ever, cases have been reported that occured in
children8,9 as well as in patients in their seven-
ties.2 The average age at which this disease has
occurred is 35 to 40 years. 2 r',7,9,1° The disease
occurs in males 3 to 10 times more frequently
than in females. 2,11

Upper respiratory infections commonly pre-
cede the onset of acute nonspecific pericarditis.
The severity of such infection may vary from a
simple respiratory infection to an atypical pneu-
monia. Its incidence has been reported in from
37 to 54 per cent of cases, 2,r’-7,9 with 1 series re-
porting an incidence of 80 per cent."

Pain is the predominant symptom of acute
nonspecific pericarditis and occurs in practically
all patients at some time during the course of
their illness. Typically, it occurs rather abruptly
after an indefinite period of malaise. It is usually
substernal in location, with radiation to the left
chest and shoulder. The pain is accentuated by
deep respiration, cough, motion, and swallow-
ing.2 The difficulty in differentiating this pain
from that of acute myocardial infarction is ob-
viouslv great. The pain of acute nonspecific
pericarditis is generally less severe and less grip-
ping. Circulatory collapse is uncommon.5 Many

MARCH 1958

77

variations of this pattern of pain may occur. Two
cases presenting as acute abdominal conditions
in which surgical exploration was carried out
and 1 case presenting as low back pain have been
reported.2-12

Dyspnea is a prominent symptom in approxi-
mately one-half of the patients.2,5’7 5' It may be
present even in those patients who do not show
evidence of effusion or pulmonary infiltrate.
Severe pain caused by respiration may cause
rapid, shallow respiration.9

Fever is present in 80 to 90 per cent of the
reported cases.2-57'9 It should be emphasized,
however, that its presence is not essential in
establishing this diagnosis.9 The elevation of
temperature is usually in the range of 100 to 103°
F. Tachycardia is also common.

Pericardial friction rnb is the most important
physical finding and is present in over 70 per
cent of reported cases.2'5'7 9 '1 Typically, the rub
occurs early and may be transient or may last
for several days. If all patients could be ex-
amined at the time of onset of the first symptoms
of malaise, the reported incidence of pericardial
friction rub would probably be much higher.
The rub heard in acute nonspecific pericarditis
is typically scratchy and to-and-fro in nature.9
It is usually heard over a relatively large area
to the left of the sternum.2 A pericardial fric-
tion rub usually precedes electrocardiographic
changes.2 It is thought that the disappearance
of a friction rub is often coincident with the ap-
pearance of pericardial effusion.9

Leukocytosis is present in one- to two-thirds
of the cases,2'7 9 usually ranging from 10,000 to
15,000 cells per cubic millimeter. Leukopenia is
rare but has been reported.2 Elevation of the
sedimentation rate may be expected in from 70
to 90 per cent of cases. The highest sedimenta-
tion rate in any given case varied from 15 mm.
per hour to over 100 mm. per hour in one re-
ported series.7 The return of an elevated sedi-
mentation rate to normal has proved an accurate
index of improvement in clinical status.5

Electrocardiographic changes in pericarditis
are characteristic and are almost invariably pres-
ent and, therefore, are of great diagnostic value.
These changes are due to the pericarditis per se,
the extent of injury to the subepicardium and
possibly, to deeper layers of the myocardium,
and to the amount of pericardial effusion." The
elevation of the S-T segment with upward con-
cavity in one or more leads occurs early. Within
a period of a few days to a week, this elevation
returns to the normal isoelectric level. Shortly
thereafter, the T wave becomes inverted in
several of the limb and unipolar limb and chest

leads. A discordant relation of the T wave in
leads I and III occurs very seldom, and a signifi-
cant Q wave almost never appears.13 The in-
verted T waves usually become upright in six to
twelve weeks, but Carmichael reported 6 patients
with apparently permanent T wave inversion
following acute nonspecific pericarditis.5 Pro-
longation of the P-R interval, which is common
in rheumatic pericarditis, is not seen in acute
nonspecific pericarditis.7 Since a changing elec-
trocardiographic pattern is characteristic of peri-
carditis, the necessity of taking serial tracings
when this disease is suspected is obvious.

Enlargement of the cardiac silhouette as shown
by x-ray examination is a common finding in
acute nonspecific pericarditis. It is present ap-
proximately 50 per cent of the time.2'5 Much
controversy exists concerning whether the en-
largement of the cardiac silhouette represents
cardiac dilatation or pericardial effusion or both.
Ordinary roentgen examination usually does not
resolve the problem.7 Opinions in the literature
vary from stating that cardiac enlargement is
commonlv due to pericardial effusion2 to state-
ments that cardiac dilatation is the cause of
enlargement in 94 per cent of the cases.5 That
pericardial effusion can cause enlargement of the
cardiac silhouette has been proved by pericardio-
centesis.9 Cardiac tamponade in acute non-
specific pericarditis is relatively uncommon. For
this reason, pericardiocentesis has been per-
formed infrequently in this disease. Price and
associates,14 in reviewing this subject in 1956,
found reported records of only 20 pericardio-
centeses that had been performed in acute non-
specific pericarditis. In 10 of these patients,
serous fluid was obtained, and, in the other 10,
sanquineous effusions were present. In no case
was a sanquineous effusion reported before the
tenth day of illness. The use of angiocardio-
graphy has been suggested as a practical method
of differentiating pericardial effusion from card-
iac dilatation.15 Recent improvements in surg-
ical technics have made pericardial biopsy and
the creation of a pleuropericardial window prac-
tical.10 This method of treating cardiac tamp-
onade caused by pericardial effusion will prob-
ably replace pericardiocentesis in the future.
Therefore, angiocardiography diagnostically may
become increasingly important.

Approximately one-half of the patients show
evidence of pulmonary involvement, occuring
as pneumonitis, pleuritis, and/or pleural effu-
sion.2-7'9 Pleural effusion has been reported in 25
per cent of tbe cases.17 Effusions are usually left-
sided or bilateral. Right-sided effusions are un-
common.2 When pleural effusion is present, it

78

THE JOURNAL-LANCET

should, ot course, he examined in an attempt to
establish a specific etiology.

ETIOLOGY

The etiology of acute nonspecific pericarditis is
unknown, as its name implies. The widely differ-
ing course of the disease from one case to an-
other suggests that the condition can be caused
by more than one agent.7 It is generally felt that
acute nonspecific pericarditis is a viral disease,
although a specific virus has as yet not been
identified. That viruses can cause pericarditis
has been shown by its coincident occurrence in
diseases of known viral etiology. Instances have
been reported of its occurrence in association
with lymphogranuloma venereum,18 Bornholm
disease,19 and primary atypical pneumonia.20 A
relationship between acute nonspecific pericar-
ditis and infectious mononucleosis has also been
reported.2122 Evidence supporting the virus
theory is the antecedent respiratory infection,
the occasional occurrence of the disease in epi-
demics, and its usually benign course. Against
the viral etiology is the fact that virus organisms
have never been recovered from a pericardial
effusion.9 Significant cold agglutinin titers in
patients with acute nonspecific pericarditis rarely
occur.2,7 The usual lag between the respiratory
infection and the pericarditis and the usual pres-
ence of leukocytosis also mitigate against the
virus theory of etiology.

Dressier'" has suggested that acute nonspecific
pericarditis is of rheumatic etiology. He stresses
its great similarity to the postcommissurotomy
syndrome, which is thought to be of rheumatic
origin. He also stresses the fact that acute rheu-
matic fever in adults is often an atypical, benign
process which may heal without residual heart
disease. This and the fact that acute nonspecific
pericarditis is primarily a disease of adults, he
feels is more than mere coincidence. Against the
rheumatic theory is the infrequency of joint in-
volvement in this disease. A history of acute
rheumatic fever in the past is rare. When peri-
carditis does occur in acute rheumatic fever, it
seldom becomes manifest before the joint symp-
toms are noted.23 No pathologic evidence of
rheumatic disease has been obtained in cases
of acute nonspecific pericarditis which have
come to surgery or necropsy.2

Tuberculosis has often been advanced as an
etiologic explanation of acute nonspecific peri-
carditis. The well-known fact that pericarditis,
as well as pleural and pericardial effusions, may
occur with tuberculosis and may defv specific
diagnosis for long periods of time favor this
theory. Aganist this theorv is the fact that peri-

carditis in tuberculosis is usually painless and
seldom, if ever, runs a benign course. Surprising-
ly, little information is available in the literature
regarding the incidence of positive tuberculin
reactions in acute nonspecific pericarditis. One
author states the tuberculin reaction is often
negative.5 Another reports 5 positive reactors in
10 patients.2

Many other etiologic theories have been postu-
lated. Cases have been reported occurring in
allergic diseases.24 Toxins have been implicated
by some who point to the frequent occurrence
of pericarditis in uremia to support this hypo-
thesis. The relationship of acute nonspecific
pericarditis to polyserositis and to various types
of arteritis is often mentioned but has not been
fully investigated in either instance.9

PATHOLOGY

Although pathologic reports in acute nonspecific
pericarditis are few in number, owing to its gen-
erally benign course, those reports that are avail-
able all establish the pericardial nature of the
disease. An organizing, nonspecific pericarditis
is found. Coronary vessels and myocardium are
grossly normal. Polymorphonuclear leukocyte in-
filtration of the myocardium adjacent to the
epicardium has been described.9

DIFFERENTIAL DIAGNOSIS

The diagnosis must be made by carefully exclud-
ing other forms of acute pericarditis and other
diseases which cause chest and abnominal pain.
The specific causes of acute pericarditis listed
in the introduction often become apparent after
an adequate history has been taken, a physical
examination has been done, and appropriate
laboratory studies have been obtained. The pres-
ence of pain alone, however, introduces a large
number of diagnostic possibilities, including myo-
cardial infarction, coronary insufficiency, pneu-
monia, pleuritis, mediastinitis, pleurodynia, her-
pes zoster, intercostal neuralgia, diaphragmatic
hernia, and acute abdominal conditions.9 Of
these, the most important by far and often the
most difficult to differentiate is acute myocardial
infarction. The treatment and prognosis in acute
nonspecific pericarditis anti acute myocardial in-
farction are quite different, as will be noted.
Krook7 reviewed the cases of acute myocardial
infarction occuring in patients under the age of
45 at Mahno General Hospital in Sweden from
1943 to 1952 anti found that 4 cases were diag-
nosed acute myocardial infarct, where as, in
retrospect, these patients actually had had acute
nonspecific pericarditis. In general, this exper-
ience has probably been the rule rather than the

MARCH 1958

79

exception. The onset, location, and radiation of
pain may be similar in both diseases, but the
accentuation of pain by motion, respiration, and
coughing favors pericarditis. The pain is usually
more severe in myocardial infarction, and cir-
culatory collapse is more common. Both diseases
occur predominantly in males, but acute non-
specific pericarditis occurs generally in a younger
age group. History of an antecedent upper res-
piratory infection and/or the presence of pul-
monary inflammation, as well as the early ap-
pearance of a pericardial friction rub, all favor
the diagnosis of acute nonspecific pericarditis.
Leukocytosis and elevation of the sedimentation
rate occur earlier in pericarditis. The importance
of serial electrocardiograms when this diagnostic
problem arises cannot be overemphasized. Trans-
aminase determinations may become an increas-
ingly useful diagnostic study, often being ele-
vated in myocardial infarction and normal in
pericarditis.

Dressier25 recently reported 10 cases of pleuro-
pericarditis after proved myocardial infarction
which have closely mimicked acute nonspecific
pericarditis, which he calls the "post infarction
syndrome.’ Its significance is not as vet clear.

COURSE AND PROGNOSIS

The natural course of acute nonspecific pericar-
ditis may be summarized in the following man-
ner. It is usually a benign disease. Recurrences
are frequent. Late chest pain is common. Con-
strictive pericarditis is seldom a late complica-
tion. The electrocardiogram may occasionally
show persistent abnormalities.

This disease usually runs a benign course,
lasting anywhere from two to seventv days with
an average of approximately two weeks. How-
ever, 5 fatal cases have been reported in the
literature.14’26-29 Cardiac tamponade, although
rare, should be watched for carefully because
pericardiocentesis or the surgical creation of a
pleuropericardial window may be lifesaving in
such a situation.

Recurrences have been reported in 15 to 35
per cent of the cases. 2-i r,’7 ° Recurrent episodes
of acute nonspecific pericarditis are usually less
severe than the initial attack and are seldom pre-
ceded by an upper respiratory infection. Tran-
sient bouts of vague chest pain of varying inten-
sity, occurring months and even years after the
initial illness, have been even more common in
the few patients in whom an adequate follow-up
has been possible.5

Although all authors agree that constrictive
pericarditis is a rare sequal to acute nonspecific
pericarditis, opinions differ greatly as to whether

it actually happens. Dalton and associates,30 in
reporting 78 cases of constrictive pericarditis,
stated that an intensive study was not made to
elucidate the etiology of the disease. However,
one fact stood out, and that was that when the
etiology was unequivocal, it was invariably tuber-
culous. Carmichael,31 in 1955, stated that no
well documented cases of chronic constrictive
pericarditis occuring after acute nonspecific peri-
carditis had been reported. Rabiner and associ-
ates32 reported a case of a patient in whom con-
strictive pericarditis developed after nonspecific
pericarditis, who was treated surgicallv with good
results. Many aspects of the case, however, sug-
gested a tuberculous etiology. In another series
of surgically treated patients with pericardial
effusion, Proudfit and Effler16 reported 5 cases of
sanquineous pericardial effusion of undetermined
etiology. They suggested that chronic constric-
tive pericarditis would probably have developed
later in these patients. Krook7 feels that the late
sequelae of constrictive pericarditis is more fre-
quent than we suspect and reports 2 such cases
occurring after acute nonspecific pericarditis.
He also points to the high frequency with which
adherent pericarditis is found at autopsy in pa-
tients dying of other causes and the fact that in
only a relatively small percentage of such cases
was a history of pericarditis due to a specific
etiology elicited in their medical history.

Three patients showing evidence of residual
myocardial injury long after the initial acute
nonspecific pericarditis had subsided have been
reported.17 Persistent, apparently permanent,
electrocardiographic changes have been reported
in as much as 12 per cent of the patients.5 These
changes have consisted primarily of abnormal T
wave inversions. The appearance of such T wave
abnormalities in an otherwise healthy young
male suggests the possibility that an undiagnosed
acute nonspecific pericarditis has occurred at
some time in the past.

TREATMENT

The treatment of acute nonspecific pericarditis
is symptomatic. Patients may be ambulated as
soon as their symptoms allow, although activity
should be limited until all signs and symptoms
of their disease have disappeared.2 Because of
the potential complication of hemorrhagic peri-
cardial effusion,1416 which may be fatal,27 29 the
use of anticoagulants is definitely contraindicated
and again emphasizes the importance of earlv
accurate diagnosis of this disease.

There is an occasional report in the literature
suggesting that antibiotics are of value in treat-
ment.33'34 Most authors, however, are of the

80

THE JOURNAL-LANCET

opinion that antibiotics are of no specific bene-
fit.35'36

The use of corticotrophin and cortisone has
been reported in the treatment of patients with
acute nonspecific pericarditis who were very
toxic and steadily becoming more ill. Reports
of at least 12 patients so treated are available.2’8'
0,37-39 jn ajj |1U(- one instance,9 the course of the
patient’s illness promptly improved and the pa-
tient recovered. When cortisone was discon-
tinued, one patient38 suffered a relapse but re-
sponded when cortisone therapy was resumed
and remained well after it was gradually discon-
tinued three weeks later. It is postulated that
the steroid therapy suppresses inflammatory re-
sponses during the acute phase of the illness but
does not otherwise alter the natural course or
duration of the disease.8 It would seem that the
use of steroids in a dosage equivalent to 25 mg.
of cortisone four times a day is indicated in a

REFERENCES

1. Cecil, R. L., and Loeb, R. F.: Textbook of Medicine, ed. 9.
Philadelphia, W. B. Saunders Co., 1955.

2. Scherl, N. D.: Acute nonspecific pericarditis; survey of the
literature and study of 30 additional cases. J. Mt. Sinai Hosp.,
N. Y. 23:293, 1956.

3. Hodges, R. M.: Idiopathic pericarditis. Boston Med. & Surg.
J. 51:140, 1854.

4. Barnes, A. R., and Burchell, H. B.: Acute pericarditis sim-
ulating acute coronary occlusion. Am. Heart J. 23:247, 1942.

5. Carmichael, D. B., Sprague, H. B., Wyman, S. M., and

Bland, E. F.: Acute nonspecific pericarditis. Clinical, lab-

oratory and follow-up considerations. Circulation 3:321, 1951.

6. Reeves, R. L.: Cause of acute pericarditis. Am. 1. M. Sc.

225:34, 1953.

7. Krook, H.: Acute nonspecific pericarditis; study in 24 cases

including descriptions of 2 with later development into con-
strictive pericarditis. Acta med. scandinav. 148:201, 1954.

8. Friedman, S., Ash, R., Harris, T. N„ and Lee, H. F.:
Acute benign pericarditis in childhood; comparisons with rheu-
matic pericarditis, and therapeutic effects of ACTH and cor-
tisone. Pediatrics 9:551, 1952.

9. Reid, E. A. S., Hutchison, J. L., Price, J. D., Smith, R. L.:
Idiopathic pericarditis. Ann. Int. Med. 45:88, 1956.

10. Dressler, W.: Idiopathic recurrent pericarditis; comparison

with postcommissurotomy syndrome; consideration of etiology
and treatment. Am. J. Med. 18:591, 1955.

11. Goyette, E. M.: Acute idiopathic pericarditis. Ann. Int.

Med. 39:1032, 1953.

12. Powers, P. P., Read, J. L., and Porter, R. R.: Acute idio-
pathic pericarditis simulating acute abdominal disease.
J.A.M.A. 157:224, 1955.

13. Gelfand, M. L., and Goodkin, L.: Acute benign nonspecific
pericarditis without a pericardial friction rub. Ann. Int. Med.
45:490, 1956.

14. Price, J. D., Hutchison, J. L., and Reid, E. A. S.: Benign
idiopathic pericarditis; fatal case with a review of the fatalities
in the literature. Am. Heart J. 51:628, 1956.

15. McGuire, J., and others: Nonspecific pericarditis and myo-

cardial infarction. Circulation 14:874, 1956.

16. Proudfit, W. L., and Effler, D. B.: Diagnosis and treat-
ment of cardiac pericarditis by pericardial biopsy. J.A.M.A.
161:188, 1956.

17. Godfrey, J.: Myocardial involvement in acute nonspecific

pericarditis. Ann. Int. Med. 35:1336, 1951.

18. Sheldon, W. H., Wall, M. J., Slade, J. De R., and Hey-
man, A.: Lymphogranuloma venereum in a patient with
mediastinal lvmphadenopathv and pericarditis. Arch. Int.
Med. 82:410,' 1948.

19. Bower, B. D., Gerrard, J. W., and MacGregor, M.: Acute
benign nonspecific pericarditis; report of 4 cases in childhood.
Brit. M. J. 1:244, 1953.

20. Finkelstein, D., and Klainer, M. J.: Pericarditis associated

severely ill patient.38 The evaluation of such non-
specific therapy in a usually benign disease must
be evaluated critically and such therapy should
not be used indiscriminately. We must remem-
ber that the use of a “blister” one century ago
was thought to be helpful specific therapy.3

SUMMARY

1. The incidence and diagnosis of acute non-
specific pericarditis have been discussed.

2. The most prevalent theories of etiology have
been presented.

3. The difficulty and importance of differenti-
ating acute nonspecific pericarditis from acute
myocardial infarction have been emphasized.

4. Recurrences are common, but late compli-
cations in acute nonspecific pericarditis are rare.

5. Treatment is symptomatic. The careful use
of corticotrophin or cortisone may be indicated
in selected cases.

with primary atypical pneumonia. Am. Heart J. 28:385,
1944.

21. Miller, H., Uricchio, J. F., and Phillips, R. W.: Acute

pericarditis associated with infectious mononucleosis. New
England J. Med. 249:136, 1953.

22. Soloff, L. A., and Zatuchni, J.: Infectious mononucleosis

associated with symptoms of acute pericarditis. J.A.M.A. 152:
1530, 1953.

23. Furman, R. H.: Acute nonspecific pericarditis. Am. Pract.

& Digest Treat. 3:869, 1952.

24. Zivitz, N., and Oshlag, J. A.: Eosinophilic pleural effusion
and pericarditis with effusion in an allergic subject. J. Aller-
gy 20:136, 1949.

25. Dressler, W.: A complication of myocardial infarction re-

sembling idiopathic recurrent benign pericarditis. Twenty-
eighth scientific session, Am. Heart Assoc., New Orleans, Oct.
24, 1955, Abst., Circulation 12:697, 1955.

26. Pomerance, M., Perchuk, E., and Hoffman, J. B.: Fatal

case of idiopathic pericarditis. New York J. Med. 52:95,
1952.

27. McCord, M. C., and Taguchi, J. T.: Nonspecific pericarditis;
a fatal case. Arch. Int. Med. 87:727, 1951.

28. Case records of Mass. Gen. Hosp. New England J. Med.
234:608, 1946.

29. Case records of Mass. Gen. Hosp.; weekly clinicopathologic ex-
ercises. New England J. Med. 254:707, 1956.

30. Dalton, J. C., Pearson, R. J., Jr., and White, P. D.: Con-
strictive pericarditis; review and long term follow-up of 78
cases. Ann. Int. Med. 45:445, 1956.

31. Carmichael, D. B.: Natural course of acute nonspecific peri-
carditis. U. S. Armed Forces M. J. 6:534, 1955.

32. Rabiner, S. F., Specter, L. S., Ripstein, C. B., and
Schlecker, A. A.: Chronic constrictive pericarditis as sequel
to acute benign pericarditis; report of case. New England
J. Med. 251:425, 1954.

33. Taubenhaus, M., and Brams, W. A.: Treatment of acute

nonspecific pericarditis with aureomycin. J.A.M.A. 142:973,
1950.

34. Marois, A., and Marcoux, G.: Acute benign nonspecific

pericarditis. Canad. M. A. J. 75:834, 1956.

35. Parker, R. C., Jr., and Cooper, H. R.: Acute idiopathic

pericarditis. J.A.M.A. 147:835, 1951.

36. Christian, H. A.: Nearly 10 decades of interest in idiopathic
pericarditis. Am. Heart j. 42:645, 1951.

37. Kursban, N. J., and Iglauer, A.: Acute nonspecific peri-

carditis: report of case treated with ACTH. Ohio M. J. 47:
915. 1951.

38. Rakov, H. L.: Acute nonspecific idiopathic pericarditis; re-

port of case treated with orallv administered cortisone. Arch.
Int. Med. 98:240, 1956.

39. Weiss, M. M.: Acute idiopathic pericarditis treated with cor-
tisone. J. Kentucky M. A. 50:393, 1952.

MARCH 1958

81

Spontaneous Subarachnoid Hemorrhage

RUDOLPH J. RIPPLE, JR., M.D.

St. Paul, Minnesota

Subarachnoid hemorrhace is typically defined
as a sudden onset of headache, often with the
feeling that something has snapped in the head
and followed by a greater onset of severe oc-
cipital pain, nausea, and vomiting with pro-
nounced rigidity of the neck muscles, positive
Kernig’s and Brudzinski’s signs, and blood by
spinal puncture. These symptoms are caused by
free blood in the subarachnoid space.

INCIDENCE

Spontaneous subarachnoid hemorrhage is said
to be responsible for 2 per cent of sudden un-
explained deaths.1 Baker- savs that it is the
second most common cause of central nervous
system deficit in the young adult age group. The
sex incidence in various series shows that the
distribution is just about equal.

The disease is generally conceded to have an
incidence of about 1/15 that of a cerebrovascular
accident ( thrombosis or intracerebral hemor-
rhage). Berg3 noted that polycystic disease of
the kidney is definitely associated with berry
aneurysms (one of the causes of spontaneous
subarachnoid hemorrhage). He found aneu-
rysms could be noted in 1 per cent of autopsies,
but, in patients with polycystic kidney disease,
16 per cent had intracranial aneurysms at autop-
sy. He also feels there is an association between
intracranial aneurysms and hypertension, coarc-
tation, and patent ductus arteriosus.

ETIOLOGY

The etiology of subarachnoid hemorrhage varies
to a degree with different authors because of
their exclusion of different entities. Trauma and
birth injury are excluded by the definition “spon-
taneous.” Therefore, anything that produces
blood in the subarachnoid space fits the classifi-
cation. Included in the causes are extension of
an intracerebral hemorrhage into the subarach-
noid space, arteriosclerosis, congenital aneu-
rysms, syphilis, septic emboli, angiomas, blood
dyscrasias, acute hemorrhagic infections, eclamp-
sia, tumors, thrombosis of a longitudinal sinus,
and even subdural hematoma. In most of these

rudolph j. ripple, jR. w a medical resident at the
Veterans Administration Hospital, Minneapolis.

conditions, however, very small amounts of
blood appear in the subarachnoid space. Gross-
ly bloody fluid usually indicates rupture of a
blood vessel in the subarachnoid space— usually
an aneurysm, arterial angioma, or arteriovenous
malformation. Walton,4 excluding atherosclerotic
intracerebral hemorrhage bursting into a ven-
tricle, trauma, and birth, listed these factors as
the causes of the disease: aneurysmal rupture,
80 per cent, rupture of an angioma or arterio-
venous malformation, 10 per cent, and other con-
ditions, 10 per cent.

This discussion will be concerned with the two
former conditions.

CLINICAL FEATURES

There is scarcely a more dramatic syndrome in
its onset and development than subarachnoid
hemorrhage. Most authors do not correlate ex-
ercise with onset, but, in McCutchan’s1 pa-
tients, two-thirds were working hard at time of
onset. The characteristic symptoms of this dis-
ease are the result of blood irritating the me-
ninges and increasing the cerebrospinal fluid
pressure. There are, however, general systemic
symptoms, localizing symptoms in some cases,
and some which suggest etiology.

The symptoms caused by blood entering the
subarachnoid space depend on the speed at
which the bleeding occurs. If bleeding occurs
slowly, the patient may have onlv a headache
and stiff neck for a week, or he may rapidly
lose consciousness within a few minutes if the
blood loss is sufficiently extensive. In the average
case, there is an acute onset of a violent head-
ache, often accompanied by a feeling that some-
thing has snapped inside the head, and followed
by vertigo, vomiting, and stiffness of neck in 50
per cent of cases. Most patients pass at least
into a state of semistupor, but some never lose
consciousness. The majority of patients lie in an
attitude of general flexion, resent interference,
and are confused and irritable when aroused.
During this period, moderate pyrexia is com-
mon, photophobia is not unusual, and seizures
occur in 3 per cent.4 Findings due to the in-
creased intracranial pressure include papillede-
ma, which is usually slight, occurring most often
on the side of the hemorrhage, though it may

82

THE JOURNAL-LANCET

he bilateral. Subhyaloid hemorrhages are not
uncommon. Fundi changes are usually related
to the proximity of the optic nerves to the hem-
orrhage. Other nonlocalized findings are those of
third or sixth nerve palsies and diminution of
tendon and abdominal reflexes.

Localized findings are most frequent when the
etiologic bleeding point is closely applied to
brain substance, that is, anterior communicating
and middle cerebral ruptures are more likely to
cause localization than rupture of the internal
carotid artery, which is loose in the subarach-
noid space.

Focal symptoms are more likely to occur with
rupture of an arteriovenous malformation, in the
ratio of 8:1, but these are, of course, of no help
in diagnosing the individual case.

Premonitory signs occur most often with the
angiomatous malformation but also can occur
with aneurysms, consisting of visual field defects,
focal seizures, previous bleeding episodes, and
migrainous-type headaches. Laboratory findings
include pvrexia, leukocytosis, occasional albumi-
nuria and glycosuria, and increased spinal fluid
pressure. For two to three days, the fluid is
grossly bloodv and, providing bleeding stops, is
xanthochromic for about two to three weeks.
The protein content is elevated, though rarely
above 100 mg. There can be up to 3,000 white
blood cells in the fluid ( dilution of the blood ) .

The diagnostic workup should include skull
roentgenograms and an electro-encephalogram,
although usually both are noncontributory. The
skull film may occasionally show calcification in
the case of an angioma. The differential diag-
nosis is only in doubt in the occasional case in
which the patient is so comatose that his neck
is not stiff, in which case, the diagnosis is that
of the comatose patient. Ordinarily, the only
question is that of meningitis, and the spinal
tap for pressure, cells, culture, smear, and pro-
tein rules this condition out. Incidentally, menin-
geal irritation is the one indication for spinal tap
with choked disk. However, even then it can
cause herniation of the medulla and should be
carefully performed.

There is some differential symptomatology of
angioma versus aneurysm, and these findings
differ to a certain degree with the position and
pathology. Let us first discuss the aneurysm.

Intracranial aneurysm. Pathologically, the
berry aneurysm is a 1 to 5 mm. (up to 30 mm.)
swelling at the junction of two of the compo-
nents of the circle of Willis or at a bifurcation
of one of the cerebral arteries. Brain5 feels that
the aneurysm may be congenital, but it is apt
to develop at any time in life on the basis of

congenital structural deficiency, that is, a weak-
ness in the media. Microscopically, these media
are extremely narrow and fibrous, and the elastic
and muscular elements are absent. Brain states
that 80 per cent of these rupture sooner or later,
but Hamby0 reports an autopsy incidence in all
patients of about .5 to 1 per cent. Aneurysms
are felt to be multiple in 15 per cent of cases.

Where are the lesions most likely to occur?
Again, this is difficult to assess as they are listed
as ruptured, unruptured, and arteriosclerotic, in-
clusive, in different series. A fairly typical series
of locations of ruptured aneurysms is that found
in Baker’s- book, which lists McDonald’s series
of 786 cases.

Anterior communicating, 109
Middle cerebral, 247
Anterior cerebral, 75
Internal carotid, 106

| unction of internal carotid and posterior communi-
cating, 26

| unction of anterior cerebral and anterior communi-
cating, 28

Posterior communicating, 29
Posterior cerebral, 23
Basilar, 89
Vertebrals, 42

The posterior fossa ruptures are felt to con-
stitute about 25 per cent of the ruptures.

It has been previously mentioned that aneu-
rysms are less likely to cause symptoms prior
to rupture than arteriovenous malformations,
but Brain5 feels that 25 per cent may cause
symptoms prior to rupture. However, recurrent
headache is the symptom he lists as most
frequent, which makes it valueless as a diagnos-
tic, localizing procedure. Internal carotid aneu-
rysms, however, may produce visual field de-
fects. Middle cerebral aneurysms may cause
monoplegia and hemiplegia and result in con-
vulsions prior to rupture. Posterior fossa (ver-
tebral and basilar arteries) may cause crossed
hemiplegia.

Angiomatous malformations. These are rarer
than aneurysms, of course, being responsible for
about 1 per cent of neurologic admissions. They
are best divided into 3 types:

1. Telangiectasis is a small group of dilated
capillaries. The condition occurs in Rendu-Osler-
Weber disease. Of rare significance clinically in
rupture because it rarelv causes symptoms.

2. Venous angiomas are wedge- or cone-
shaped masses of veins which may be superficial
but usually extend deeply into white matter.
These too are uncommon causes of hemorrhage.
These produce no bruit and do not enlarge
because they have no arterial supply. They are
relatively less symptomatic than the next group.

3. Arterial angioi7ias ( arteriovenous aneurysms)

MARCH 1958

83

are also wedge-shaped lesions extending deep
into the brain parenchyma. They are sup-
plied with blood by one or more large arteries.
For that reason, they can enlarge. Also, they
may contain arteriovenous fistulae. They are
composed of arterial-like vessels, as opposed to
the venous angiomas. The arteriovenous fistulae
in these lesions may be of sufficient magnitude
to cause heart failure.1

These lesions are predominantly in the domain
of the middle cerebral artery, thereby contrib-
uting to their seriousness. Because of this com-
mon distribution in one-half of them, a frequent
presenting symptom is epilepsy. Because of
their intracerebral nature, these lesions are much
more apt to produce symptoms prior to a hem-
orrhage. Of differential diagnosis, there are, ac-
cording to Mackenzie,7 ( 1 ) multiple previous
bleeding episodes and (2) focal seizures. These
factors greatly favor ruptured arteriovenous mal-
formation over a ruptured berrv aneurysm, as do
(3) progressive neurologic deficit prior to hem-
orrhage, (4) bruit, which is diagnostic, and (5)
migrainous headaches prior to hemorrhage, but
these conditions can occur too with an internal
carotid aneurysm.4 During the acute hemor-
rhage, the ruptured arteriovenous lesion usually
causes more direct brain damage because of its
location, but this is not of help in the diagnosis of
an individual patient. In 70 per cent of patients
with angiomas, the first symptom occurs before
age 30.

TREATMENT

There are almost as many methods of treatment
as there are authors, and lack of controlled
studies is to be expected because of the emer-
gent nature of the disease and the fact that each
patient must be treated individually.

Most physicians feel that the patient should
be treated conservatively until the bleeding
stops. The patient should be made as comfort-
able as possible and restlessness should be al-
layed so that further bleeding will not occur.
Phenobarbital and codeine are indicated. Hour-
ly vital signs should be observed, and tempera-
ture must be taken each four hours because fever
is often the first sign that bleeding has recurred.
Walton4 feels that lumbar puncture should not
be used as a daily routine treatment, not so
much because it may cause bleeding to recur
but because he feels the procedure is of no bene-
fit and may introduce herniation of the medulla,
fie repeats lumbar puncture only for intense
symptomatology, the inspection of continued
fresh bleeding, or evaluation of surgical treat-
ment. Most all authors believe in taking only

a few cubic centimeters, which can be used for
cell-count culture and protein, and the pressure
can still be reduced somewhat for comfort.
Fluids, of course, should be given to maintain
the electrolyte situation. From this point on,
the treatment varies. If the patient fails rapidly,
some authors feel that nothing can be done.8
Others feel that immediate carotid ligation in the
neck should be done as an emergency measure.

Usually, however, after the third day, the
bleeding has stopped, and most authors feel
that angiography is indicated. Bilateral carotid
angiography should be done because 20 per
cent of aneurysms are multiple, and, in the case
of anterior aneurysms, one must know the
source from which they are fed and on which
side they are located. Twenty per cent of the
carotid angiograms are negative. Basilar angio-
grams are felt to be indicated by some. Others
do not believe they are worthwhile because of
the difficulty in assessing them surgically. The
angiogram can demonstrate both aneurysms and
arteriovenous malformations.

Norlen and Olivecrona8 feel that the time for
surgery in at least one-half of the patients should
be between three to fourteen days after hemor-
rhage occurs, because after that the vessels di-
late, the clot loosens, and bleeding is most apt
to recur. This is the point at which treatment
of the angiomatous malformation and the berrv
aneurysms differ.

The aneurysms differ as to location:

1. Intracranial internal carotid aneurysms are
the easiest to attack surgically by the intracra-
nial trapping method and comprise about 25
per cent of all aneurysms.

2. Anterior communicating and anterior cere-
bral aneurysms include 28 per cent of demon-
strated aneurysms. These are more difficult to
treat, particularly because they feed from both
sides in so many instances. French9 has had
much success in treating this tvpe.

3. Middle cerebral aneurysms comprise 30
per cent of these lesions. Their prognosis is poor
because of the difficulty in trapping the aneu-
rysm and the resultant hemiplegia."

4. Vertebral and basilar arteries offer little
surgically, but some authors have done vertebral
artery ligation with success.10

The surgical attack on aneurysms, as well as
on malformations, is the only real hope for im-
provement in prognosis. The majority of authors
feel that the attack on intracranial aneurysms is
no better than conservative measures in the first
three days but that it provides protection against
later recurrence.11 Recurrences can occur as late

84

THE JOURNAL-LANCET

as twenty years after the original hemorrhage.

Surgical attacks on angiomas or arteriovenous
malformations are at best rather poor because of
the deep infiltrating nature of the lesions. A few
respond to radiation. Carotid ligation is not so
valuable. Block resections of areas of the brain
have been performed with some success. Occa-
sionally, tying off a feeding vessel can help, but
it is difficult to decide and be sure whether it
is the only feeding vessel.

There is no really controlled series from which
to determine whether surgery is better than med-
ical treatment because no group contains the
same patients. Falconer cites mortality rates of
50 to 60 per cent in conservatively treated pa-
tients as against 20 per cent after surgery. How-
ever, his was a group of only 50 patients. Most
authors believe that surgery offers the only hope
for increasing recoveries after the first three days.

PROGNOSIS

The prognosis is worse, of course, with increas-
ing age,4 recurrent bleeding, and severe neuro-
logic signs. Most authors found that about one-
third of nonsurgically treated patients died dur-
ing the first attack and 20 per cent more after
a recurrence in the second week.12

Hamby’s report'-’ shows, in 130 cases treated
conservatively, a 45 per cent mortality with
first attack and 72 per cent of survivors in the
second attack. Symptoms which seem to pre-
dispose to poor prognosis in the first attack in-
clude coma for more than one day, high blood
pressure, hemiplegia, high temperature, recur-
rent fever, and convulsions.4 Hvland13 feels, like
others, that an angiomatous etiology presents a
much graver situation because the brain tissue
is much more apt to be involved. Walton col-
lected 1,300 cases throughout the literature and
found that 581 (44.7 per cent) died in the first
eight weeks, which included the first recurrence.

REFERENCES

1. McCutchan, G. R.: Spontaneous subarachnoid hemorrhage.

Am. J. Med. 17:528, 1954.

2. Baker, A. B.: Clinical Neurology. New York: Paul B.

Hoeher, Inc., 1955.

3. Berg, R. L.: Subarachnoid hemorrhage; case report. New

England J. Med. 252:594, 1955.

4. Walton, J. N.: Prognosis and management of subarachnoid
hemorrhage. Canad. M. A. J. 72:165, 1955.

5. Brain, Sir Russell: Diseases of the Nervous System. Lon-
don: Oxford University Press, 1955.

6. Hamby, W. B.: Intracranial Aneurysms. Springfield, Illi-

nois: Charles C Thomas, 1952.

7. Mackenzie, I.: Clinical presentation of cerebral angioma.

Brain 76:184, 1953.

Of his own group, Walton says that of the 120
survivors he was able to follow, 4 per cent were
completely disabled. Of the rest, one-third had
fairly serious sequelae, consisting of paralysis
10 per cent, convulsions 13 per cent, severe head-
ache 37 per cent, mental deterioration 9 per cent,
and anxiety 27 per cent. Another one-third had
trivial sequelae and one-third had no symptoms.
Comparative studies are very hard to analyze in
those who have had surgery because of differ-
ences in age, surgical technic, location of aneu-
rysm, and the type of operation. However, the
general impression is that the prognosis is better
after the first three days.2 In Falconer’s series
of 50 who were treated surgically, mortality was
only 20 per cent, and only 3 patients were dis-
abled after surgery. Not as great a number of
series has been treated surgically as conserva-
tively, and, in medical series, reports varied from
28 to 63 per cent deaths. For that reason, statis-
tics at present mean little. In Jacobson’s14 group
of medically treated patients, 11 per cent of
those who recovered were permanently maimed.
The prognosis of recurrence after the first six
months of those who live another six months
is only 10 per cent.4 The prognosis in surgically
treated patients varies with the site and type
of operation, but it is felt that surgery greatly
decreases the possibility of later bleeding.

SUMMARY

Some factors about symptoms and prognosis of
subarachnoid hemorrhage have been discussed.
It is apparent that longer periods of study are
required before final conclusions can be drawn
concerning the most effective type of treatment.
Spontaneous subarachnoid hemorrhage is a seri-
ous disease with a rather poor prognosis. It is
felt that surgical technics reduce the death rate
to some extent and offer the greatest hope of
cure.

8. Norlen, G., Olivecrona, H.: Treatment of aneurysms of

circle of Willis. J. Neurosurg. 10:404, 1953.

9. French, L.: Personal communication.

10. Falconer, M. A.: Surgical treatment of bleeding intracranial
aneurysms. J. Neurol., Neurosurg. & Psychiat. 14:153, 1951.

11. Rowe, S. N., Grunnagle, J. F. and others: Results of direct
attack on intracranial aneurysm. J. Neurosurg. 12:475, 1955.

12. Cecil, R. L., and Loeb, R. F.: Textbook of Medicine, ed. 5.
Philadelphia: W. B. Saunders Co., 1956.

13. Hyland,. H. H.: Prognosis in spontaneous subarachnoid

hemorrhage. Arch. Neurol. & Psychiat. 63:61, 1950.

14. Jacobson, S. A.: Analysis of some factors in spontaneous

subarachnoid hemorrhage. Arch. Neurol. & Psychiat. 72:712,
1954.

MARCH 1958

85

Rectal Bleeding in Infants and Children

J. C. RATHBUN, M.D., F.R.C.P.(C).

London, Ontario

Rectal bleeding is a fairlv common com-
plaint in an office practice dealing with in-
fants and children. In hospital practice, on the
other hand, it is a much less common but much
more serious sign. Blood in the stool is always
disturbing to parents and, fortunately, leads
them to the physician. Because of the grave
implications in hospital cases and the necessity
for the physician to decide between serious and
benign lesions, it is important that all of these
children be regarded carefully. Any case of
rectal bleeding demands a detailed history and
physical examination with a rectal and procto-
scopic examination when indicated. Even with
the most careful study, some 10 to 20 per cent
of cases cannot be clearly diagnosed. For this
reason, the examination must be meticulous in
all details.

In taking the history of these patients, it is im-
portant to learn the nature of the blood passed:
its color, whether clotted or not, whether mixed
with stool or not, whether there is mucus or pus,
its amount and duration, and any associated
symptoms. The relationship to the bowel move-
ment may be helpful. This detailed description
of the stool must be obtained. If possible, the
physician should see the stool himself.

Armed with this information, a differential
diagnosis can be outlined which precludes cost-
ly mistakes. As a general rule, bright red blood
passed by the bowel has been said to come from
the lower portion of the gastrointestinal tract,
and, although this is generally true, it may prove
wrong in specific cases. The various causes of
rectal bleeding are shown in table 1. These are
grouped according to the appearance of the
blood in the stool. The first column shows the
commoner causes of bright red blood in the stool,
and the second column shows the rarer causes.

To avoid errors of omission, all these diag-
noses must be considered. When bright and

j. c. rathbun is professor of pediatrics at the Uni-
versity of Western Ontario and pliysicmn-in-chief of
The War Memorial Children’s Hospital, London,
Ontario.

Presented to the Canadian Medical Association,
June 20, 1957, at Edmonton, Canada.

dark red blood is mixed, the causes usually stem
from disorders higher in the gastrointestinal
tract, which are shown in column 3. Black and
tarry blood, due to the action of hydrochloric-
acid which produces acid hematin, is usually
the result of lesions in the upper gastrointestinal
tract or above, which are shown in column 4.

There are several substances which can be
confused with blood and, on occasion, cause dif-
ficulty. These are shown in column 5. Parents
often mistake blood in the stool for the red color
produced by various drugs, such as Achromycin.
One of our recent cases of intussusception was
not seen for thirty-six hours because the parents
mistook blood and mucus for the Achromycin
the child was taking by mouth. Beets are a well-
known offender, and uric acid leaves a pink stain
on the diaper which may mislead the unwary.

This discussion will be limited to the first and
most important group, that in which bright red
blood is passed by bowel. However, it must be
remembered that the stool findings depend on
the state of motility of the bowel as well as the
size of the hemorrhage. Thus, any of the condi-
tions outlined in the third and fourth columns
can produce bright red blood in the stool if
bowel motility is increased and the hemorrhage
is fairly large.

In approaching this problem, the first consid-
eration is the frequency with which these out-
lined causes occur. Table 2 indicates the relative
incidence in hospital practice of the various con-
ditions which may cause bright red rectal bleed-
ing. These figures represent the incidence over
a five-year period of the causes seen in column
1 of table 1. The difference between hospital
experience and office practice is striking.

The most frequent and serious cause of blood
in the stool is intussusception. This condition
must be excluded at once in any case of rectal
bleeding, for a missed diagnosis in such instances
may be fatal. This is the group in which many of
our diagnostic difficulties arise. Classically, in-
tussusception occurs primarily between the ages
of 5 and 7 months in a well child. The onset
is usually characteristic, with sudden, violent,
crampy pain and vomiting unassociated with
diarrhea but accompanied by progressive shock.

86

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TABLE 1

CAUSES OK RECTAL BLEEDING

■■ ■-- - - - A-

Common

Rare

Mixed blood

Black

Common errors

Intussusception

Foreign body

Purpura

Nosebleed

Drugs — Achromycin

Leukemia

Hemorrhoid

Trauma

Peptic ulcer

Foods — beets

,\ 1 cckel’s divert iculu m

Purpura

Peptic ulcer

Violent vomiting

Uric acid

Fissure-in-ano

Hemophilia

Typhoid

Esophageal varices

Rectal polyp

Mesenteric I hrombosis

Nursing blood

1 lemophilia

Hemorrhagic disease

Erythroblastosis fetalis

1 lemophilia

Purpura

Volvulus

Obstructive jaundice

Neoplasm

Trauma

Dysentery
Nursing blood

Neoplasm

Hemorrhagic disease
Colitis

I lemorrhagic disease
Nursing blood
Tonsillectomy
Duplication of bowel

TABLE 2

the stool.

It is imperative to

diagnose intussus-

CAUSES OF RECTAL BLEEDING
CHILDREN’S HOSPITAL. 1951-1955

Intussusception

26

Leukemia

17

Meckel’s diverticulum

13

Fissure-in-ano

12

Rectal polyp

9

Hemorrhagic disease

6

Volvulus

5

Dysentery

i

89

ception within twenty-four hours after the onset
if resection of necrotic bowel is to be avoided.

Kiesewetter and associates1 recently pointed
out the importance of chronic recurrent sigmoid
intussusception. In the case of a dolichocolon,
the redundant sigmoid may readily telescope
down into the lower bowel when the child
strains. This has been revealed by sigmoidosco-
py. The leading edge may then bleed and pro-
duce melena.

Treatment is tending to revert to medical

These symptoms should suggest the diagnosis
before the appearance of the typical bloody, cur-
rant jelly stools. A palpable, sausage-shaped,
doughy tumor may be felt in the right upper
quadrant, and blood is obtained on rectal ex-
amination. With increasing clinical awareness,
only about half of our cases have bloody stools
when they are first seen.

Diagnosis may be confirmed by barium enema
with the results shown in figure 1, which shows
clearly the “coiled spring” appearance of the in-
tussusception. Our greatest difficulty has been
with ileoileal intussusception in which a charac-
teristic story is given, but no mass is palpable
and no blood is passed by rectum. This condi-
tion must be diagnosed by a flat plate of the
abdomen showing small bowel obstruction with
fluid levels when the child is held upright as
seen in figure 2. This should be followed by
barium enema. The commoner ileocecal type
and the rare colicocolic type cause less diagnos-
tic difficulty because blood appears earlier in

mm wmmm

Fig. 1 . Intussusception showing “coiled spring” appear-

MARGH 1958

87

Fig. 2. Flat plate of abdomen showing small bowel ob-
struction with fluid levels.

management by barium enema reduction. This
reflects the management of over one hundred
years ago,2 and, in careful hands with conserva-
tive management, 50 per cent of cases can be
satisfactorily reduced.3 However, if reduction
fails or if a second intussusception occurs, sur-
gical intervention is essential. Since about 10
per cent of cases have a Meckel’s diverticulum,
lymph gland, polyp, or tumor of the bowel which
precipitates the bowel intrusion, an operation is
necessary to remove the cause. Many small bowel
lesions are difficult to demonstrate clinically, and
a laparotomy may be the only successful method.
Even with surgical exploration, some cases recur
two or three times without explanation.

Leukemia usually bleeds late in its course
when other signs and symptoms make the differ-
entiation easy. This error can be avoided with
a routine blood count. Similarly, the various clot-
ting and nutritional disturbances usually produce
other signs and symptoms.

Meckel’s diverticulum or omphalomesenteric
duct with hemorrhage is a clinical diagnosis.
These cases present with either bright or dark
red, massive, painless bowel hemorrhage, with
clots and no other findings. The Meckel’s diverti-
colum is difficult, if not impossible, to demon-
strate by x-ray with contrast media, and only one
or two have been demonstrated in Victoria Hos-

pital, London, Ontario, in the past ten years. A
laparotomy is performed in these cases only
after a second occurrence of bleeding unless the
initial hemorrhage has been extreme. This pre-
vents unnecessary operation, for it is well accept-
ed that small bowel lesions are practically un-
detectable, and many other causes may be con-
fused with a hemorrhaging Meckel’s diverticu-
lum. For example, reduplication of bowel, which
also has gastric mucosal rests in it, is not in-
frequently mistaken for Meckel’s diverticulum.
The management is the same — laparotomy. In
all cases, the patient is transfused preoperatively
as blood loss may be considerable.

Fissure-in-ano is the commonest cause of
bleeding in infancy that is encountered in office
practice. A hard stool produces a fissure and a
blood-streaked stool in an infant. These fissures,
in contradistinction to adults, are readily healed
by keeping the stools soft with a mild laxative
and the fissure clean by washing, followed with
an antibiotic ointment containing tyrothricin,
bacitracin, or other nonabsorbable antibiotics.
On this routine, the fissure usually heals in about
one to two months. The radical surgery used in
adults is not necessary and is contraindicated.

Rectal polyp, the fifth cause of bleeding in
hospital patients, is accepted as the commonest
cause of massive rectal bleeding among patients
in office practice. Blood is passed often after a
stool. Diagnosis is easily made by doing a rectal
examination, when most of these tumors are pal-
pable within 1 in. of the anal orifice as a rounded
mass the size of a pea. These are mucosal polyps
and are often pedunculated. The remainder can
be readily visualized by proctoscope and re-
moved by fulgurization. Occasionally, these tu-
mors develop at the anus as shown in figure 3.

Fig. 3. A polyp which developed at the anus.

88

THE JOURNAL-LANCET

Furthermore, polyps are sometimes multiple
in quantity and distributed throughout the colon.
These cases of multiple polyposis are familial in
nature and usually have a more fibrous center
which gives them a different gross appearance.
These are frequently associated with pigmenta-
tion of lips.4 5 Coller11 has pointed out that these
lesions invariably become malignant, and he
recommends early colectomy. This procedure
should not be undertaken until the polyps have
been confirmed by two successive barium ene-
mas in order to be sure they are not fecal balls.

Hemorrhagic disease of the newborn is the
most common cause of bleeding in this period.
It usually occurs on the third or fourth day post-
partum and is accompanied by bleeding from
the navel, vagina, kidney, nose, or by the vom-
iting of blood. Diagnosis can be made by clot-
ting time and prothrombin time estimations.
This condition is treated by the administration
of fresh blood and vitamin K. Our English col-
leagues7 recently pointed out the danger of
hemolysis that an excess amount of vitamin K
may produce. They suggest that only 2 mg. be
given and repeated once if necessary.

Hemorrhagic disease of the newborn must not
be confused with nursing blood or swallowed
blood. Apt* has shown that 35 to 40 cc. of blood
swallowed by an infant appears bright red in
the stool in nine to thirty hours. The presence
of this maternal blood can be determined by
taking 1 cc. of blood and diluting it to 5 cc. with
distilled water. To 5 cc. of this solution, 1 cc.
0.25 NNaOH is added. Maternal blood turns
brown, while fetal blood turns pink.

Volvulus and mesenteric thrombosis are in-
frequent causes of rectal bleeding but must be
considered in young infants with small bowel
obstructions. The frequent congenital defects
which come to light in this age group are usually
the precipitating factors, such as malrotation of
the gut and persistent omphalomesenteric duct.
Characteristically, these babies present with tre-
mendous abdominal distention, vomiting, crampy
abdominal pain with tinkling bowel sounds,
blood and mucus in one stool, and then no stools
thereafter. A roentgenogram reveals signs of
small bowel obstruction, and the treatment is,
of course, surgical.

Dysentery is a more frequent cause of blood
in the stool than the figures indicate. The diag-
nosis is usually not difficult, for the child has
diarrhea with blood flecking or small drops of
blood in the stool. This arises from ulceration
of the small or large bowel. Culture of the stool
reveals, in most cases, a member of the Salmo-
nella group. Treatment with a broad-spectrum

Fig. 4. Photograph shows multiple purpuric spots in a
child with Henoch’s purpura.

antibiotic usually controls this infection. Chronic
ulcerative colitis produces similar stools.

Two of the rarer causes of rectal bleeding
which appeared in this series were Henoch’s
purpura and rectal prolapse. The purpura fol-
lowed two weeks after an upper respiratory in-
fection. This child presented with multiple pur-
puric spots ( figure 4 ), and then bloody mucus ap-
peared in her stools which resembled intussuscep-
tion, as crampy abdominal pain accompanied it.

The second patient had severe prolapse of the
rectum following malnutrition. This condition
is usually accompanied by bright red rectal
streaking, and, of course, the diagnosis is obvi-
ous (figure 5). Treatment consists of restoring

an”*

Fig. 5. Patient with severe prolapse of the rectum.

MARCH 1958

89

nutrition, strapping the buttocks, and adminis-
tration ot a sufficient amount of laxative to keep
stools soft. Rarely, sclerosing solutions or sur-
gical suspension are necessary.

In conclusion, a review of the various causes
of rectal bleeding shows a considerable differ-
ence in the frequency of the types of cases seen
in office and hospital practice. In the former,
anal fissure and rectal polyps are the usual
causes, while intussusception and Meckel’s di-
verticulum are the important types seen most
often in the hospital. It is because of the last
two conditions that no case of rectal bleeding
should be ignored, as both may be fatal or at

REFERENCES

1. Kiesewetter, W. B., Cancelmo, R., and Koop, C. E.:
Rectal bleeding in infants and children. J. Pediat. 47:660,
1955.

2. Meigs, J. F., and Pepper, W.: Diseases of Children. Phila-
delphia: P. Blakiston, Son & Co., 1886. p. 494.

3. Childe, A.: Annual meeting, Canad. Paediat. Soc., Winni-

peg, 1957.

4. Behrer, M. R.: Jejunal polyposis with intussusception and

melanin spots. J. Pediat. 38:641, 1951.

least produce serious stigmata for the rest of the
patient s life after bowel resection.

The difficulty of diagnosing ileoileal intussus-
ception has been stressed, and a high index of
suspicion must be maintained if errors in diag-
nosis are to be avoided. The diagnosis of intus-
susception during an epidemic of gastroenteritis
is extremely hazardous.

A careful and detailed history and physical,
rectal, and proctoscopic examinations with roent-
genograms, where indicated, help to prevent
tragedy in eases of rectal bleeding. Clinical
judgment in these cases may be taxed to the
limit.

5. Baffes, T. G., and Potts, W. J.: Blood in stools of infants
and children. Pediat. Clin. North America 2:513, 1955.

6. Coller, F. A.: Cancer of Colon and Rectum. Am. Cancer
Soc., Inc., monograph, 1956, p. 94.

7. Crosse, V. M., Meyer, T. C., and Gerrard, J. W.: Kemic-
terus and Prematurity. Arch. Dis. Childhood 30:501, 1955.

8. Apt, L., and Downey, W. S., Jr.: Melena neonatorum;

swallowed blood syndrome. J. Pediat. 47:6, 1955.

Eighty per cent of premature infants pass their first stool within twenty-four
hours after birth and 94 per cent within forty-eight hours. In comparison, 94
per cent of normal full-term infants pass the first stool within twenty-four hours.

Meconium retention in the newborn period suggests intestinal obstruction.
Delayed or infrequent passage of meconium, with or without signs of intestinal
obstruction, may be the first sign of Hirschsprung’s disease.

Stimulation of the rectum with a thermometer or an enema of 10 to 15 cc.
of normal saline may result in free passage of meconium. If not, and if other
symptoms develop or a stool is not passed within the next twelve hours, the
abdomen should be examined by roentgenograms for distended loops of bowel.
If no abnormalities are seen, sterile water feedings may be instituted and th('
infant watched closelv until a stool is passed.

All premature infants who have not voided bv twentv-four hours should be
observed carefully . If the external genitalia show no obvious abnormalities and
the kidneys do not appear enlarged bv palpation, the general condition of the
infant determines further diagnostic measures.

Irving Kkamer, M.D., and S. Norman Sherry, M.D., Sinai Hospital, Baltimore. J. Pediat. 51:
.373-376, 1957.

90

THE JOURNAL-LANCET

Office Gynecology

EDWARD A. BANNER, M.D.
Rochester, Minnesota

Though patients with gynecologic disabili-
ties comprise a large part of general prac-
tice, most medical school curricula and hospital
teaching programs are so filled that there is in-
sufficient time to stress office procedures in gyne-
cology. The material that I shall present is based
on personal observations and experiences with
practicality in mind.

Much may he learned from casual observation
of the gynecologic patient as she walks into the
office that may aid in diagnosis. Obtaining a his-
tory is still a great art. Diagnoses are often sug-
gested by the history and may be missed if the
physician is not a good listener. In many in-
stances, a complete physical examination is re-
quired. This examination may reveal systemic
causes for the gynecologic symptoms or extra-
gynecologic lesions with symptoms that might
be incorrectly interpreted to be of gynecologic
origin.

The conditions to which the gynecologist’s at-
tention is called most often include inflammatory
and infectious diseases, new growths, sequelae
of labor, and endocrine dysfunctions that pro-
duce aberrations of menstruation. The patient
often seeks counsel because of abnormal vaginal
secretions, genital bleeding, or pelvic pain. Less
often she may come because of protruding
masses or generalized pelvic or abdominal dis-
comfort. Still others may visit the office because
of the persistent “cancer drives,” which make
them apprehensive and desirous of reassurance
from the physician.

Whatever the cause, the number of such pa-
tients in the office of the gynecologist is increas-
ing, for most clinics report that more and more
patients go to the “office” gynecologist rather
than to the “surgical” gynecologist. The net
result is to place greater responsibility on the
physician, for, if mass education sends more
patients to him, he will be expected to detect

edward a. banner is a consultant in the Section of
Obstetrics and Gynecology at the Mayo Clinic and
is assistant professor of obstetrics in the Mayo Foun-
dation.

Read at the meeting of the Southwestern Medical
Association, El Paso, Texas, October 9 to 11, 1957.

processes in earlier stages when treatment can
be swift and effective and lives can be saved.

HISTORY

Much can be learned from an adequately taken
history, which often reveals significant illnesses
or symptoms that are otherwise missed. Many
patients who come to the office with gynecologic
complaints have no demonstrable organic dis-
ease. Often, they are merely indicating anxiety,
fear, resentment, or guilt. The practical gyne-
cologist must be a physician well skilled in the
practice of gynecology and also a practical
psychologist. He must integrate into his diag-
noses the personality of the individual in order
to treat her ailments properly. The following
word of caution perhaps should be introduced
here: the diagnosis of functional illness must be
established not only by exclusion of organic dis-
ease but also on the basis of its own characteris-
tics as well. Certain diseases can be treated by
psychologic advice, but it is also possible to treat
a neurotic individual incorrectly by physical
measures. The best way to avoid improper, un-
necessary, or even harmful treatment is to be
sure of the diagnosis.

The medical history should provide pertinent
information about the patient’s family, her social
background, occupation, sexual habits, marital
problems, and so forth. Occasionally, the physi-
cian must be rather obtuse in exploring personal
problems with the patient, for, if approached too
directly, she may set up an antagonistic defensive
attitude and obstruct further enlightening dis-
cussion. A distinguishing characteristic of the
competent clinician is his ability to sense intui-
tively that which the patient is trying to express
and to let her vent her feelings in such a manner
that she will not be offended by apparent accusa-
tions. In gynecology more than any other speci-
alty, the combination of disease with sexual prob-
lems requires an understanding of the psychology
that was developed many years before.

PHYSICAL EXAMINATION

A general physical examination should follow the
history and should, whenever possible, precede
the pelvic examination.

MARCH 1958

91

What to look for. In the general examination
of the patient, much can be learned at a glance
about her habitus and whether she has masculine
or feminine characteristics, is robust or frail,
hirsute or balding. The temperature, pulse rate,
and blood pressure should be recorded. The
breasts should be examined, for, as secondary
sex characters, they share in many changes and
physiologic conditions within the pelvis.

In the abdominal examination, the physician
should note the presence or absence of striae
indicative of rapid loss of weight and evidence
of past pregnancies or endocrine dysfunction.
Tender areas should be carefully palpated, and
distinction should be made between rigidity and
normal muscular defense reaction. Although an
adequate abdominal examination is neglected by
many, it actually may bring to the fore the pri-
mary difficulty at hand, especially if the patient
is acutely ill or apprehensive. Incidentally, a
full bladder has, at times, deceived the shrewdest
of examiners. For this reason, some gynecologists
have the patient void immediately before ex-
amination to forestall such a diagnostic pitfall.

Pelvic examination. Whatever is learned after
the history and the physical examination must be
gained tactually and correlated with information
gained from both these procedures. To develop
the tactile sense, one should do enough pelvic
examinations to acquire the faculty of instant
recognition not only of the normal anatomic re-
lationship but also the minor aberrations that are
the hallmarks of pelvic disease. One should be-
come familiar with the nodular, tender areas in-
volving the uterosacral ligaments and posterior
uterine surface, so characteristic of endometrio-
sis, and also with the thickened, tender, and bul-
bous swelling of the tubes portraying the after-
math of pelvic inflammatory disease.

Equipment. All the necessary equipment for
the proper performance of a pelvic examination
should be at hand before the examination is be-
gun. This includes drapes, hand protection, lu-
bricants, light, material for taking smears, and a
table that offers the examiner every advantage.

Since the speculum is an indispensable instru-
ment to the gynecologist, a word shoidd be said
regarding the various types available. For most
purposes, the bivalve speculum is satisfactory.
It is made in several sizes, and the examiner
selects the size that can be introduced easily and
does not cause the patient discomfort. In child-
ren, the most satisfactory speculum is the tubular
cystoscope, which is used with the patient in the
knee-chest position. The tubular speculum is
available in various sizes. For some patients, the
flat Sims speculum may be used to advantage.

Rapprochment with patient. Establishing the
patient’s confidence is the greatest single factor
in promoting ease of examination. Unconsidered
remarks or chance actions that engender fear,
resentment, or anxiey may result in a tense, dis-
turbed, or apprehensive patient. Such a patient
is rigid and ill at ease and in a state that may
make pelvic examination impossible or seriously
unproductive. In creating confidence, gentleness
is the first essential. Relaxation may be encour-
aged by asking the patient to breathe through
her mouth. Constant reassurance is helpful. No
violation of modesty shoidd enter the pelvic ex-
amination, but exposure should be consistent
with thoroughness. The presence of a nurse or
an assistant may aid in this respect. Most of all.
the physician should maintain an attitude of
kindly and impersonal thoroughness. A pelvic
examination is not a pleasant experience for any
woman, and the success with which it is con-
ducted depends as much on the attitude of the
physician and his assistant as on the actual sit-
uation in the pelvic region.

What to look for. Inspection of the external
genitalia is done with the patient in the lithotomy
position and with the physician standing be-
tween the patient’s knees. The vulva is inspected
for dermal lesions, excessive secretions, and mas-
ses. Since vulvar neoplasms frequently metasta-
size to the inguinal lymph nodes, these nodes
shoidd be palpated for tenderness or enlarge-
ment. Small, shotty inguinal nodes are not un-
usual, especially in young women, and should
cause no concern unless they are associated with
definite lesions.

After examination of the vulva, the labia
should be gently parted, and the size, shape, and
dermal changes, if present, shoidd be noted care-
fully. Inspection for kraurosis vulvae, lichen
sclerosus et atrophicus, and leukoplakia should
be made. Normally, Bartholin’s glands shoidd
not be palpable, and Skene’s glands should not
be tender. If the hymen is intact, examination
of the pelvic organs may be completed recto-
abdominally. Careful note should be made of
the caliber of the introitus. By pressure exerted
downward against the perineal bodv during
vaginal examination, more space may be ob-
tained with less discomfort to the patient.

The condition of the pelvic floor is then deter-
mined. To ascertain the presence or absence of
rectocele is not difficult but may be rendered
easier by pressure exerted upward on the pos-
terior vaginal wall through the rectum. The size,
shape, consistency, and position of the cervix
shoidd then be determined by palpation. A nor-
mal cervix is said to have the consistency of the

92

THE JOURNAL-LANCET

end of the nose, whereas a cervix invaded by a
malignant process generally has a hard or grittv
consistency.

At this point, examination with the speculum
is begun. It is well to recall that the axis of the
vagina is directed posteriorly, while the long axis
of the introitus is anteroposterior. It is desirable
to introduce the bivalve type of speculum, with
its transverse axis vertical to conform to the
shape of the vaginal orifice. This is preceded by
separating the vulva and applying pressure on
the perineal body. When it is well past the en-
trance of the vagina, the speculum is turned so
that the blades lie transversely, with the tip of
the speculum pointed posteriorly toward the
vaginal floor when the blades are opened. The
common practice of using soap or lubricants is
not advisable, since soap alters the chemical
reaction of the vaginal secretions and interferes
with staining and cultural reactions. Lubricants
also frequently make interpretation of Papani-
colaou stains for malignant cells more difficult
or even impossible. Rather, it is better to wet the
gloved hand and speculum with warm water,
thereby decreasing the shock to the patient and
offering adequate lubrication.

With the aid of a strong light, the cervix is now
visualized directlv. Its size, position, and length,
as well as the nature of its secretions, are noted.
This is the moment at which an old adage be-
comes most significant: “Examine the cervix with
a strong light and with a suspicious mind.” A
smear for study by the Papanicolaou technic may
be taken. Secretion should be taken from both
the internal os and the vaginal pool. Samples
may be obtained with either a wooden spatula
or a cotton applicator. The secretion is spread
on a clean glass slide which is dropped immedi-
ately into a solution of 95 per cent alcohol. Be-
cause of the danger of explosion, ether should not
be added to the solution of alcohol stored about
the office.

Next, the cervix is inspected for evidence of
cystic change, lacerations, or erosions. A speci-
men of any abnormal tissue that is seen should
be taken for biopsy before definitive therapy is
offered. Such a specimen should always be ob-
tained if cervical erosions are present, and care
should be exercised to secure adequate tissue
from the squamocolunmar junction. This should
be done before cervical cauterv is attempted.
The application of Lugol's solution will demar-
cate those areas most applicable for biopsy.

Normal cervical and vaginal epithelium con-
tains glycogen, whereas abnormal epithelium,
such as that found in erosions or a malignant
lesion, contains little or none at all. Hence, by

applying a weak solution of iodine (one-fourth
strength tincture of iodine) to these areas, a
marked differentiation may be obtained rapidly.
Normal tissue becomes a deep mahogany brown
and the pathologic surface turns pink. Speci-
mens for biopsy should be taken from the pink
or light areas. One must be cognizant of the fact
that the Schiller or iodine test is not specific for
any type of lesion, nor does it distinguish malig-
nant from benign tissue. It merely demarcates
the areas from which specimens of tissue for bi-
opsy should be taken. There is no special time
in the menstrual cycle when the specimen for
biopsy should be obtained. In this regard, the
endocervix should not be neglected, because the
introduction of a small sound or cotton applicator
within the cervical canal ( the so-called Clark
test) often discloses a pathologic process that
otherwise might have been missed.

Many women present with bleeding after sub-
total hysterectomy. Under such circumstances, a
small endocervical curet may be used to obtain
tissue for examination. If small endocervical
polyps are the cause of the bleeding, this curet-
tage may be therapeutic as well as diagnostic. It
is always well to submit all such material to a
competent pathologist for careful examination
and evaluation.

It is also a wise practice to remove all polyps
that may be found extruding from the cervix.
Polyps can be removed easily by torsion. This
procedure should be followed by fulguration of
their bases. All polyps should be examined by
a competent pathologist. Before the speculum
is removed, the condition of the vaginal walls
should be observed, with attention given to the
presence or absence of excoriations or new
growths.

The bimanual examination, which would better
be known as the “vaginal-abdominal examina-
tion,” can be made with fingers of either hand
within the vagina. From a practical standpoint,
especially if tbe physician practices obstetrics, it
is useful to develop ambidexterity in this per-
formance. With the examiner’s fingers resting
against the pelvic floor, the cervix is palpated,
while the examiner’s other hand is placed flat on
the lower part of the patient’s abdomen. By
elevating the palm and using the tactile sense in
the balls of the fingers rather than in the tips, the
various organs are located, steadied, and evalu-
ated. The size, shape, and consistency of each
structure can be determined, and, if tumors pro-
ject into the superior strait, their outlines can be
noted.

.After the cervix has been palpated, the pres-
ence or absence of pelvic pain on motion is de-

MARCH 1958

93

termined. The position of the uterus is ascer-
tained by locating the body of the organ. When
the uterine fundus lies in its normal relationship,
it is usually in an anteflexed position. Retroces-
sion or retroflexion occurs normally in a high per-
centage of women. The mobility of the uterus
may then be thoroughly tested. Immobility or
excessive pain on uterine motion may be indica-
tive of chronic infection, acute exacerbation of
chronic infection, adhesions, or endometriosis.
When the median part of the pelvis has been
palpated and the condition of the uterus has
been determined, the examining fingers are now
slid into one of the fornices lateral to the uterus.
The abdominal hand is directed in a like plane
and is moved slowly and deliberately.

Next, the examiner’s fingers in the vagina are
pushed out into the lateral fornix, while the hand
resting on the abdomen is directed in a like
plane. The ovary is then palpated between the
tips of the fingers of both hands. A normal ovary
is sensitive and mobile. Ovaries that are retro-
cessed within the pelvis are best examined later
bv the recto-abdominal approach. The physician
should become familiar with the normal size of
an ovary and should keep in mind its tendency
to enlarge after contralateral oophorectomy and
hysterectomy. The normal ovary feels like an al-
mond; it is about 4 cm. long and 2 to 3 cm. wide.
Normally, it moves within a limited range.
Occasionally, its mobility may become abnormal
and it may be situated immediately lateral to the
cervix, within the cul-de-sac, or high on the lat-
eral pelvic wall.

Normal fallopian tubes usually cannot be pal-
pated through the vagina. However, if they are
thickened or are the sites of chronic residual
changes from infection, they may be sensed as
masses of hornlike shape which occasionally are
fluctuant and many times are tender, firm, and
resistant.

Rectal examination should be done for all
patients who complain of difficulties referable
to the pelvis, and it is especially indicated for
young women with an intact hymen. When a
pelvic malignant process is present, the recto-
abdominal examination gives, perhaps, more in-
formation than any other. The necessity for an
empty bowel is clear. Care should be taken not
to exert too much pressure against the anterior
wall of the bowel, for that structure may be ex-
tremely tender. Should abnormalities be noted,
proctoscopic examination is indicated.

Lesions within the vagina and cervix occasion-
ally may be seen best by examining the patient
in the knee-chest position. The vagina is easily
distended with air, making the vaginal rugae

disappear and allowing the walls of the vagina
to be seen clearly. Children and young girls are
best examined in this position and with the aid
of a Kelly cystoscope.

At times, it may be necessary to anesthetize the
patient in order to carry out pelvic examination.
An anesthetic is indicated only after repeated
pelvic examinations have been entirely unsuc-
cessful, sometimes with several days intervening.
One should be aware not only of the usefulness
of this procedure but also of its limitations.
Naturally, examination of the pelvis with the
patient under anesthesia has no value when the
cooperation of the patient is needed; for example,
to locate sites of pain or minimal discomfort. In
general, the more nearly complete and the more
accurate the pelvic examination is, the less fre-
quent is the need to resort to anesthesia in diag-
nosis.

VAGINITIS AND LEUKORRHEA

The conditions treated most often by the gyne-
cologist in his office are vaginitis and leukorrhea.
The word “leukorrhea” actually refers to any
vaginal discharge. Usually, however, it implies
an abnormal vaginal discharge. The most com-
mon types are Trichomonas vaginitis, Monilia
vaginitis, nonspecific or Hemophilus vaginitis,
and senile vaginitis.

Trichomonas vaginitis. This type of infection
is found in all age groups and frequently occurs
during pregnancy. In 20 to 25 per cent of the
average gynecologic practice, it may be found
easilv and may be entirely asymptomatic. Actu-
ally, the causative agent is a stubborn proto-
zoan invader with a characteristic large body
about twice the size of a white blood cell. When
viewed under high power, granules are seen
within the cytoplasm and several flagella which
whip around to make the parasite motile.

The clinical picture of Trichomonas vaginitis
is characteristic. The mucosa of the vagina us-
ually appears reddened and, when the condition
is severe, presents an over-all red with straw-
berry patches. The color of the vagina, of course,
depends upon the extent and severity of the in-
fection. Usually, the infection is accompanied
by a profuse, light-yellow discharge in which air
bubbles are often entrapped, giving a character-
istic frothy or bubbly appearance. The common-
est subjective symptoms are vaginal discharge
with itching and soreness and, not infrequently,
dvspareunia. Frequently, the patient states that
the condition became exaggerated after her men-
strual period.

The diagnosis of Trichomonas vaginitis is
made by examining a small amount of the dis-

94

THE JOURNAL-LANCET

charge on a plain glass slide to which may be
added a few drops of physiologic saline solution
and a coverslip. Under the microscope, an area
showing evidence of movement is found under
the low-power objective. The high power is
then adjusted, and the motile organisms are read-
ily discernible. If the light is subdued under the
stage, the flagella may be noted whipping about
nervously, and the amebalike pseudopods are ob-
served when the trichomonads change in shape
and size. The only other vaginal invaders that
may confuse the picture are spermatozoa, but,
if one has had the opportunity to compare them
with the former at least once, the diagnosis will
never be confused.

The treatment of Trichomonas vaginitis actu-
ally should be along three lines. The first is pre-
ventive, consisting of prophylactic measures. The
patient should be taught the importance of wash-
ing her hands after a bowel movement and also
before inserting vaginal tampons during menstru-
ation. She should be instructed to wipe back-
ward with toilet paper after defecation and not
to employ the enema tip for vaginal douching.
The basic aim of the second line of treatment is
to restore and maintain the vaginal pH between
4.5 and 5 and to treat the patient during her
menstrual period. Good results have been re-
ported with many types of medication. My
colleagues and I prefer initially to insufflate the
vagina with a preparation of acetarsone ( powdex
Stovarsol compound). Each single-dose cart-
ridge contains 7 'A gr. of acetarsone. This drug is
stabilized with a soothing nonirritating diluent of
zinc oxide and salicylic acid compound. Besides
restoring the proper pH of the vagina, the prep-
aration has the added advantage of being hy-
droscopic. Even the most moist vagina and vulva
will be dry the first night after it is used, and this
in itself has a great psychologic advantage for
the subsequent treatment that may be used. We
install the first powdex treatment with the patient
in the knee-chest position and generally use 2
single-dose cartridges for this treatment. We
give the subsequent 5 daily doses with the pa-
tient in the usual lithotomy position without in-
terruption between doses for douches or other
medication. Sexual congress should be discontin-
ued until the condition is improved. In pregnant
patients, a speculum is employed during insuffla-
tion to prevent possible air embolism. Following
treatment with this compound, the patient is in-
structed in the use of vaginal suppositories, con-
sisting of a preparation of diodoquin ( Flora-
quin). Upon completion of this form of therapy,
she is re-examined after 3 menstrual periods. No
method that I know is 100 per cent successful.

Monilia vaginitis. Mycotic vaginitis is a com-
mon cause of leukorrhea. It is found most fre-
quently during pregnancy, in diabetic patients,
and in patients recently treated with broad-
spectrum antibiotics. Although other types of
yeast may produce vaginitis, Monilia, such as
Candida albicans, has been the most frequent
invader. The vagina may be covered by whitish
to grayish plaques that are adherent to the vagi-
nal wall. The most common symptoms are itch-
ing, burning, vaginismus, dyspareunia, and, oc-
casionally, frequency and urgency of urination.

The diagnosis is made in a manner similar to
that in which Trichomonas vaginitis is diagnosed.
A small portion of the discharge is placed on a
slide with a drop or two of saline solution. In
this, bamboo-like structures are found with seg-
ments, granules, and budding. Special strains
are not necessary for the diagnosis. Often, tricho-
monads, as well as Monilia organisms, are found
in the same smear.

Monilia infections most frequently respond to
the use of nystatin ( Mycostatin ) vaginal suppos-
itories. One of these is placed in the vagina in
the morning and one at night for twelve days.
Douches are not used during this period.

Nonspecific or Hemophilus vaginitis. The third
tvpe of vaginitis, which up to now has been
called “nonspecific," probably is Hemophilus
vaginitis, first reported by Leopold. The symp-
toms are less pronounced than in other tvpes
and seldom consist of more than moderate itch-
ing and burning. The leukorrhea resembles that
of trichomoniasis but usually is gray in contrast
to the yellow or white of trichomoniasis. There
is a close correlation between Hemophilus vagi-
nalis and epithelial cells with indefinite outlines
and coarsely granular cytoplasm, as seen in wet
preparations. These cells have been labeled
“clue cells” and are considered practically diag-
nostic, though a similar cell is occasionally seen
in vaginitis from other causes. A gram-stained
smear of the discharge shows large numbers ol
the typical gram-negative pleomorphic bacilli.
This organism resists culture, the most satisfac-
tory medium to date being modified sheep’s
blood agar incubated in an atmosphere of in-
creased carbon dioxide.

Treatment consists of local applications of a
vaginal cream of triple sulfonamides or, more
recently, a preparation of hexetidine ( Sterisil
vaginal sol). For Hemophilus infection of the
male urethra, treatment with one of the tetracy-
cline group of antibiotics has been suggested.
Sterisil vaginal sol has been offered as a general
therapeutic agent in the treatment of not only
Hemophilus vaginitis but also Trichomonas and

MARCH 1958

95

Candida vaginitis. Initially, research interest was
aroused in these compounds when it was demon-
strated that they inhibit glycolysis and also ad-
sorb on protein materials. Subsequent studies
demonstrated that this series of compounds has
an antibacterial spectrum similar to that of the
broad-spectrum antibiotics. This drug has been
found to be safe during pregnancy and for in-
fants and children.

Senile vaginitis. This type of vaginitis usually
occurs after the menopause but is occasionally
seen after surgical treatment, irradiation, or path-
ologic destruction of the ovaries. These patients
may complain of discharge, burning, dyspareunia
or, occasionally, a bloody, serosanguineous leu-
korrhea. The etiology rests in the loss of estro-
genic hormone with resultant atrophy and thin-
ning of the vaginal mucosa. Loss of the protec-
tive layers of the vaginal epithelium leads to
drvness and often to the formation of adhesive
bands within the vagina. Inspection reveals that
the mucosa is thin and atrophied and contains
numerous areas that bleed easilv on palpation.
The entire vaginal orifice actually may be scarred
down to one half of its normal size.

Treatment includes the use of vaginal supposi-
tories containing 0.5 to 1 mg. of stilbestrol each,
to be inserted nightly for two to four weeks be-
fore retiring. A cream of conjugated estrogenic**
substances (Premarin) has also been found effec-
tive.

NEW GROWTHS

New growths cannot be dissociated from cervi-
citis due to the various forms of vaginitis pre-
viously' described and from cervical erosions as-
sociated with cervical changes of a benign na-
ture, for, as Novak has said, despite statements in
the textbooks, it is difficult to diagnose cancer
from the gross appearance of the cervix. Some
of the worst looking cervical lesions have proved
to be benign, while others, appearing rather in-
nocuous, have proved to be manifestations of
early cancer. The moral, of course, is to take
smears or biopsv specimens if there is even the
slightest doubt, and one may paraphrase the
statement by saying that ideally every female
patient should have a Papanicolaou smear. If
cancer is suspected clinically, however, even
with negative cytologic findings, the condition
should be investigated along traditional lines.
At least 1 case in 150 of uterine cancer that
would escape the most careful scrutiny in routine
outpatient practice can be detected by the smear
technic. Furthermore, this technic can be done
in the earliest stage of the disease, when a very
high percentage of permanent cures can be justi-

fiably expected. The need for advocating earlv
diagnosis bv balanced and efficient teamwork
scarcely requires further emphasis. The method
of collecting and fixing smears is simple enough
to be suitable for use in the practitioner’s office.
The cytologic method plays a valuable role in
raising suspicion of malignant processes and in
encouraging close surveillance of the gynecologic
patient with atypical cervical epithelium. Should
this procedure become a routine in the office of
every practicing physician, there is no telling
what the over-all outcome would be, just as the
ultimate favorable outcome of Papanicolaou’s
original work of forty years ago, which was con-
cerned with the exfoliation of cells into the
vagina of rodents, was unpredictable.

chronic: cervicitis

Since every case of chronic cervicitis is potential-
ly a case of carcinoma of the cervix, early malig-
nant disease of the cervix must be excluded first.
As indicated previously, many benign-appear-
ing cervical lesions may harbor preeancerous
changes. Should the Papanicolaou stain or smear
and biopsy or conization prove that the chronic
cervicitis is actually a benign condition, the cer-
vix should be cauterized or treated otherwise.
Electrocauterization or other methods of tissue
destruction by heat applied immediately after
biopsy may bring about changes in the tissue so
that a repeat biopsy may be misleading. When
the results of biopsy are negative but the lesion
still appears suspicious, another biopsy specimen
should be taken because the original specimen
may not have been chosen from the proper site
to show malignant change. Rather than use a
cautery to stop the small bleeding points created
by biopsy, my colleagues and I apply oxidized
cellulose ( Oxycel ) or absorbable gelatin sponge
( Gelfoam ) plus an iodoform pack, which con-
trols bleeding in almost all instances. When bi-
opsy discloses chronic endocervicitis or cvstic
cervicitis, with no evidence of malignant change,
then and only then do we proceed with treat-
ment.

The active treatment of cervicitis consists of
the use of simple electrocauterv. Since the cer-
vix is devoid of sensory fibers, or nearly so, the
treatment is carried out in the office without the
use of general or topical anesthesia. Should
local anesthesia be found necessarv. either 10
per cent solution of cocaine hydrochloride or
Americaine solution may be found adequate.
We prefer to cauterize the external cervix before
the endocervical canal, since, generally, there is
more cramping with the latter procedure. We
use a radial cautery technic until all of the exter-

96

THE JOURNAL-LANCET

nal portion of the cervix up to and including the
entire site of erosion has been covered. Then the
endocervical canal is thoroughly cauterized. Be-
sides a Sims speculum, we use a Piper vaginal
retractor to keep the vaginal walls well away
from the field of operation.

It is important to tell the patient what to ex-
pect after the cautery has been done. The in-
sertion of Westhiazole vaginal suppositories or
a cream of triple sulfonamides lessens the odor-
ous discharge that may occur. The patient is in-
structed not to douche for ten days to two weeks
after cauterization and is advised to abstain from
sexual activities for approximately the same pe-
riod. She is usually told that after ten days to
two weeks, she will note a bloody, dark vaginal
discharge irrespective of her menstrual period.
However, should the menstrual period occur in
the ten-day to two-week interval, the flow is
often unusually heavy, and rest in bed is advised
during this time. All patients are encouraged to
report for re-examination two to three weeks
after the initial cautery and again after three to
six months. Patients who have undergone deep
cautery should be observed carefully for cervical
stenosis, and, before dismissal, the cervical canal
should be probed. Occasionally, after deep cer-
vical . cautery, it is necessary to use graduated
Hegar dilators to insure proper patency of the
cervical os or cervical canal.

FUNCTIONAL BLEEDING

Functional bleeding, as the name implies, means
hemorrhage from the uterus in which there are
no neoplastic or inflammatorv lesions. It is im-
portant to learn early whether the disturbance is
functional and, hence, whether the uterine bleed-
ing is originating from a proliferative or a secre-
tory tvpe of endometrium. The necessary tissue
may be obtained satisfactorily in the office in
practically all cases without anesthesia. The
Randall cannula curet is used for this purpose.
The caliber of the instrument is 4 mm., and it
can be introduced consistently into the uterine
cavity without previous dilatation. The cutting
edge of the cannula protrudes but little beyond
the periphery of the tube and allows removal of
the curet from the uterus with ease.

The actual technic used to remove tissue is
simple. The cervix and cervical canal are usually
prepared with an antiseptic, and the tip of the
cannula curet is carried to the fundus of the uter-
us. Firm pressure is placed against the uterine
wall, and then steady downward traction is
applied to the external os. Without removing the
instrument, the tip should again be carried to
the fundus and the procedure repeated in an-

other area. On withdrawal of the curet, the
specimens are found in the lumen of the instru-
ment, and they can be immediately expelled into
a fixing solution or, somtimes more conveniently,
onto thick blotting paper which is then immersed
into the solution. The blotting paper saves time
for the pathologist later on. This procedure
allows study of a considerable area of endome-
trium. Correlation of information obtained from
microscopic study of tissue removed, on the one
hand, and from the clinical history, physical ex-
amination, and estimation of the basal metabolic
rate, urinary estrin, and pituitary gonadotrophin,
on the other hand, have increased the accuracy
of diagnosis in cases of functional bleeding. Use
of the Randall curet is not advocated in patients
in whom a carcinoma of the endometrium is sus-
pected. It is better in such patients to resort to
cervical dilatation and uterine curettage.

DYSMENORRHEA

Dvsmenorrhea does not seem to plague the gyne-
cologist as much as it did years ago. However,
the various forms of treatment still are multiple
and many times complex. The pain in both pri-
mary and secondary forms of the condition is
most variable and may range from mere discom-
fort to severe agonizing pain in which the patient
may require hypodermic injections of narcotics.
Secondary or acquired dysmenorrhea is the tvpe
that usually responds well to treatment.

Examination of the patient should begin with
a complete physical appraisal and routine lab-
oratory tests, including determination of the
basal metabolic rate and the sedimentation rate.
The psychogenic background should be analyzed
carefully. Among the common causes of secon-
dary dysmenorrhea is pelvic inflammatory dis-
ease. Today, this may be present as a result of
infections from organisms other than the gono-
coccus. Heat therapy and short-wave diathermy
plus antibiotic therapy alleviate the dysmenor-
rhea that is on an inflammatory basis. Endome-
triosis is often suspected from the history.

Treatment in young girls should be conserva-
tive with the thought of preserving the child-
bearing function. Many of these patients re-
spond to the use of testosterone, estrogen, or a
combination of both. In more advanced cases of
endometriosis in which conservatism would be
ineffectual, surgical therapy must be used. Under
such conditions, the child-bearing organs should
be preserved in so far as possible. In older pa-
tients in whom the child-bearing function may be
sacrificed if necessary, the pelvis, including both
ovaries, should be cleaned out. In the younger
patients who are treated surgically, my col-

MARCH 1958

97

leagues and I prefer to do presacral neurectomy.

Primary dysmenorrhea is still the enigma of
the gynecologist, but most of the cases fit into
psychogenic, constitutional, local, or endocrine
categories. The treatment, of course, depends
upon the cause, which may be found from the
history to be a purely psychoneurotic one. A
low basal metabolic rate or general debility
should be corrected. When no specific cause is
found, various analgesics, such as aspirin, Phena-
cetin, combinations of aspirin, Phenacetin and
caffeine, or codeine should be tried. In cases of
primary dysmenorrhea that do not have a specific
cause, exercises have occasionally given much
relief by diverting the patient’s mind and in-
creasing circulation.

Endocrine therapy is not specific and does not
result in permanent cure. In many cases, how-
ever, estrogens or androgens are administered
for two to three months at a time to suppress
ovulation and relieve pain.

It should be mentioned parenthetically that
menstrual distress usually represents a combina-
tion of complaints, including periodic tension,
recurrent edema, uterine colic, and mastodynia.
Psychotherapy aimed at improving the patient’s
insight into the influence of emotions on physical
symptoms should be given over a long period of
time. To help relieve the hidden tissue edema, -
acetazolamide (Diamox) or aminometradine
(Mictine) may be prescribed for the week pre-
ceding the menstrual period. It is also suggested
that the patient take a low-sodium diet. This
regimen often relieves cyclic mammary pain as
well as headaches. The patient should also be
instructed to limit her fluid intake the week pre-
ceding her menstrual period. Ammonium chlor-
ide therapy has done much to call attention to
the theory of hidden edema, and, when used, it
should be started at least fourteen days before
the anticipated menstrual period.

The philosophy underlying the treatment of
dysmenorrhea is first of all that one should do
no harm. It is irrational to initiate a form of
therapy, the repercussions of which may be
worse than the dysfunction. Analgesics of the
opium series and some of the newer synthetic

drugs, such as alphaprodine (Nisentil) or me-
peridine (Demerol), are habit forming and
should not be used routinely or repeatedly. The
emotional component of dysmenorrhea has long
been recognized, and, certainly, suggestion enters
into any cure. Regardless of the cause of essen-
tial dysmenorrhea, some measures seem to pro-
vide partial relief, such as cervical dilatation and
uterine curettage, use of a stem pessary for var-
ious periods, pregnancy, and presacral neurec-
tomy.

SEXUAL FRIGIDITY

Complaints of sexual frigidity or sexual incom-
patibility are heard often. Clinically, of course,
such conditions have many facets and lead to
strange symptoms and signs which may conceal
the real problem. It is not surprising that these
complaints are frequent, since ignorance and
false information have long been the bugaboo in
the sexual life of the female. Many mothers still
tell their daughters that sexual relations are de-
grading, improper, or dangerous. Such teaching,
of course, leaves a permanent stigma on the mind
of the young girl, which greatly influences her
sexual behavior in adulthood. It is not unex-
pected, then, that some women develop and re-
tain a feeling of repulsion or disgust toward sex-
ual activity. Of course, not all frigidity is due to
psychogenic reasons. The majority of women
possess the capacity for pleasurable sexual activ-
ity. It is important that a wife should be com-
pletely satisfied sexually, for only then does she
become relaxed and productive in other activ-
ities. In order to advise her properly, the
physician himself must be aware of, and believe
in, the importance of good sexual adjustment and
its place in the attainment of good emotional
health. He should not have any prejudices con-
cerning sexual behavior, for, unless he is tolerant
and understanding, he will be unable to use
the psychosomatic approach. Many times, sym-
pathetic understanding of the patient in the
course of several visits is of great value in elimi-
nating unhealthy manifestations. Patients with
deep-seated neuroses and psychotic tendencies
should be referred to a psychiatrist.

98

THE JOURNAL-LANCET

Intermittent ( )bstructive Jaundice in
Hodgkin’s Disease:

o

Report of a Case

GRANT R. DIESSNER, M.D, and FRANK J. HECK, M.D.
Rochester, Minnesota

Jaundice is not uncommon in patients who
have Hodgkin’s disease. It has been reported
to occur in 3 to 6 per cent of cases,1- and some
observers think it occurs even more frequently,
since mild jaundice is overlooked at times or not
reported. However, jaundice developed in the
greatest number of the reported cases during the
terminal phase of the illness. The incidence of
intermittent jaundice in Hodgkin’s disease is un-
known, but it is thought to occur infrequently.

We are reporting the case of a patient who had
Hodgkin’s disease with intermittent jaundice in
whom the condition responded to treatment with
nitrogen mustard during 4 episodes of jaundice
in a period of two and one-half years. It is well
recognized that nitrogen mustard has a place in
the treatment of Hodgkin’s disease, but its use
in the presence of jaundice has been limited.
Dameshek and associates'1 expressed the opinion
that the presence of jaundice in Hodgkin’s dis-
ease is a contraindication to the use of nitrogen
mustard.

CASE REPORT

A 57-year-old white man, a pharmacist, was first seen
at the Mayo Clinic in January 1950. He complained of
progressive weakness, easy fatigability, backache, and
loss of 25 lb. during the past year. For nine months he
had noted abdominal fullness, bloating, and periumbilical
distress after eating solid foods.

Examination disclosed that the liver was palpable 2
fingerbreadths below the right costal margin. The tip of
the spleen was palpable. Multiple small, firm lymph
nodes were felt in the left axilla and right groin.

Urinalysis showed albumin graded 1 to 2 (on the basis
of 1 to 4), with positive results of tests for Bence [ones
protein; grade 1 erythrocytes and grade 3 pus cells were
present. The value for hemoglobin was 10.2 gin. per
100 ce. of blood. Erythrocytes numbered 4,070,000 per
cubic millimeter of blood. The leukocyte count was
24,800, with a differential count of 6 per cent lympho-

grant r. diessner is affiliated with the Section of
Medicine at the Mayo Clinic, frank j. heck is also
with the Section of Medicine at the Mayo Clinic and
is Professor of Medicine in the Mayo Foundation.

eytes, 4.5 per cent monocytes, and 89.5 per cent neutro-
phils. The erythrocytic sedimentation rate was 96 mm.
during the first hour (Westergren method). Roentgeno-
grams of the thorax, lumbar portion of the spinal column,
and the gallbladder showed nothing abnormal. The
values for urea clearance and for blood urea, calcium,
phosphate, amylase, lipase, and alkaline phosphatase
were normal.

Biopsy of lymph nodes disclosed Hodgkin’s type of
lymphoblastoma. Bacteriologic studies on the nodes
showed no growth. Roentgen treatment was given over
the abdomen, thorax, and back, but this therapy was in-
terrupted after 14 treatments because of leukopenia.

The patient returned five weeks later to complete his
course of roentgen therapy. He was feeling much im-
proved and had gained 13 lb. The leukocyte count was
normal, and the course of radiation therapy was com-
pleted without incident. The patient was dismissed in
April 1950.

He returned to the clinic for checkups in July 1950
and April 1951. He had no complaints at these times,
and significant abnormalities were not found. Treatment
was not given on either occasion.

In September 1951, the patient returned because of
fluctuating painless jaundice without fever. Occasional
dark urine and clay-colored stools had occurred during
the previous five weeks. Definite jaundice had been pres-
ent for nine days. Pruritus had appeared about three
days before admission.

The liver was firm, smooth, and palpable 2 finger-
breadths below the right costal margin. Results of rou-
tine hematologic studies were normal. Urinalysis showed
grade 2 albumin and grade 1 bile. The value for direct-
reacting serum bilirubin was 8.2 mg. per 100 cc\, and the
indirect-reacting type measured 1.8 mg. Thoracic roent-
genograms showed nothing abnormal.

The patient was admitted to the hospital for a trial of
nitrogen mustard with the provisional diagnosis of ob-
structive jaundice related to Hodgkin’s disease. A total
of 27 mg. of nitrogen mustard was given intravenously
in 2 doses; four days later, the direct serum bilirubin had
decreased to 2.74 mg. and the indirect was 1.7 mg. Two
days later, the values were 2.5 and 0.5 mg., respectively.
The patient felt greatly improved and returned home.

The patient returned in May 1952 because fluctuating
jaundice had recurred six weeks previously. He had been
free of jaundice since the aforementioned treatment with
nitrogen mustard. He felt well in the interval and had
continued to work. At the onset of this episode of jaun-
dice, he treated himself with bile salts, choline, and saline
cathartics, with some improvement. However, when this

MARCH 1958

99

self-medication was discontinued, the jaundice increased,
so he resumed medication and the jaundice became less
severe.

Results of examination were not remarkable except for
the mild jaundice. Serum bilirubin measured 1.37 mg.
direct and 0.75 mg. indirect. Bile was not found in the
urine. Values for serum protein, the albumin-globulin
ratio, hemoglobin, erythrocytes, leukocytes, platelets, pro-
thrombin time, and alkaline phosphatase were normal.
The differential count showed 11.5 per cent lymphocytes,
14 per cent monocytes, 72 per cent neutrophils, and 2.5
per cent eosinophils. Results of a thymol turbidity test
and roentgenologic studies of the thorax were normal.
Cholecystography was attempted but no function was
demonstrated.

The patient was given 27.5 mg. of nitrogen mustard
intravenously. The serum bilirubin showed no appre-
ciable change five days later, and surgical exploration of
the abdomen was advised. However, the patient decided
to return home and to postpone surgical treatment, as he
felt improved.

The patient returned in November 1953. Tire jaun-
dice again had cleared completely after the use of nitro-
gen mustard in May 1952, but it had recurred in Feb-
ruary 1953. A surgeon in his community had explored
the abdomen at that time and found a stricture of the
common bile duct and scarring in the duodenum. Chole-
cystostomy was done. Several small stones were removed
from the gallbladder, but none were found in the com-
mon bile duct. T-tube drainage was instituted, and the
jaundice cleared rapidly. The surgeon found no signifi-
cant intra-abdominal nodes or masses. External biliary
drainage was continued until June 1953. The patient
had lost 30 lb. in weight since the operation and had
noted progressive weakness. Jaundice had recurred three
weeks prior to this visit to the clinic, and he had experi-
enced retention vomiting during this period.

The liver was palpable 4 fingerbreadths below the
right costal margin, and the spleen was palpable. The
patient looked chronically ill and was extremely weak.
The value for hemoglobin was 11.3 gm.; ervthrocvtes
numbered 3,250,000; and the leukocyte count was 4,900.
The sedimentation rate was 92 mm. The serum bilirubin
measured 8.2 mg. direct and 1.0 mg. indirect. The value
for alkaline phosphatase was 86.2 King-Armstrong units.
Residts of other blood-chemical studies and of various
roentgenologic studies were normal.

Use of nitrogen mustard again was advised, and a
total of 24 mg. was given intravenously. Subjectively,
the patient felt greatly improved in twenty-four hours.
Three days after treatment, the serum bilirubin had de-
creased to 2.69 mg. direct and 0.81 mg. indirect. The
patient returned home and reported that the jaundice
cleared completely, only to recur late in January 1954.
Nitrogen mustard was given elsewhere, and the jaun-
dice again cleared and did not recur.

The patient returned for the last time in October 1954.
During the previous three or four months, he had ex-
perienced increasing anorexia, fullness in the abdomen,
vague abdominal distress, increasing weakness, nausea,
and occasional vomiting. He was ambulatory but was
pale, weak, and ill. A large, firm mass was palpable in
the epigastrium and right upper quadrant of the abdo-
men. The edge of the spleen was palpable on deep in-
spiration. Ascites and edema of both lower extremities
were present.

The value for hemoglobin was 10.8 gm. Erythrocytes
numbered 3,320,000, and the leukocyte count was 9,100.
The differential count showed 2 per cent lymphocytes,

12 per cent monocytes, 85.5 per cent neutrophils, and

0. 5 per cent eosinophils. Study of blood smears showed
increased rouleaux. The sedimentation rate was 65 mm.
Total serum proteins measured 3.48 gm. per 100 cc., with
1.98 gm. of albumin and 1.5 gm. of globulin. A test of
hepatic function using sulfobromophthalein showed grade
1 ( 10 per cent) retention of dye in one hour. The values
for blood urea and serum bilirubin were normal. Thoracic
roentgenograms showed fluid in both costophrenic angles.
Roentgenologic studies of the esophagus, stomach, and
duodenum showed an epigastric mass displacing the
lesser curvature of the stomach, but intrinsic involve-
ment of the stomach, duodenum, or esophagus was not
noted.

The patient received 2 blood transfusions of 500 cc.
each. Roentgen therapy over the entire abdomen was
given for six days. He improved, and, at the time of
dismissal, was eating well. One week later, he vomited
bright-red blood and passed tarry stools. He was hospi-
talized at home and the hematemesis continued. He was
given supportive blood transfusions, and, on November

1, 1954, abdominal exploration was done by his home
surgeon, who found a bleeding gastric ulcer and did a
partial gastric resection. Histologic study of the gastric-
wall disclosed Hodgkin’s disease. Hepatic biopsy done
at the same time showed diffuse fibrosis.

The patient’s condition became continually worse, with
progressive anorexia and loss of weight. He died in
February 1955. Necropsy was not done.

COMMENT

It is difficult to be sure of the pathophysiologic-
changes that produce jaundice in patients who
have Hodgkin’s disease. Multiple factors must be
considered. It is important, of course, to rule out
the usual causes of jaundice that are not related
directly to Hodgkin’s disease. Homologous serum
hepatitis resulting from previous parenteral in-
jections or transfusions and symptomatic hemo-
lytic anemia,4 such as that occurring in other
malignant diseases, may be responsible for jaun-
dice in these patients.

Hepatic involvement occurs in about half of
the patients who have Hodgkin’s disease,5 but
extensive changes in the liver are not common.
Beatty0 found widespread hepatic necrosis in
patients with Hodgkin’s sarcoma only when jaun-
dice had been present; necrosis of the liver was
absent in Hodgkin’s disease not associated with
jaundice. However, the group of patients studied
was small, and the hepatic necrosis may have
been related to treatment rather than to the pres-
ence of Hodgkin’s disease.

Obstructive jaundice caused by Hodgkin’s dis-
ease may occur. This diagnosis is made by ex-
cluding the commoner causes of obstructive jaun-
dice, as was done in the case just reported.
Hodgkin’s disease can produce obstructive jaun-
dice primarily bv 3 methods : namely, ( 1 ) com-
pression of the main biliary ducts by adjacent
tumor or involved nodes, (2) obliteration of the
main extrahepatic ducts as the result of ductal

100

THE JOURNAL-LANCET

involvement by Hodgkin’s granuloma, and (3)
involvement of the intrahepatic duets. Compres-
sion of the common bile duct by enlarged peri-
biliary nodes involved by the granulomatous
process is probably the most common explana-
tion given and is the assumed mechanism of
jaundice in many reports in the literature. Ex-
amination at necropsy or surgical exploration
frequently fails to bear out this explanation. The
case report by Pepper7 is illustrative of this point.
The clinical diagnosis was obstruction of the
common bile duct by nodes involved by Hodg-
kin’s disease. However, the surgeon was unable
to find any nodes that obstructed extrahepatic
biliary drainage, and the cause of the jaundice
was not ascertained.

Beatty'* recently reported the necropsy findings
in 23 cases of Hodgkin’s disease in which jaun-
dice was present at the time of death. In only
2 of these was the jaundice thought to be caused
by extrahepatic obstruction, namely, by para-
choledochal lymph nodes in 1 case and by ob-
struction at the porta hepatis in the other. How-
ever, microscopic evidence of extrahepatic ob-
struction was not present in any of these cases.
Beatty found diffuse involvement of the portal
trinities by fibrotic Hodgkin’s disease in the
patients who were jaundiced, whereas the pat-
ients who had hepatic involvement but who were
not jaundiced failed to show such involvement
of the portal trinities. Jackson and Parker8 re-
ported that jaundice caused by compression of
the bile ducts by surrounding granulomatous
tissue is rare. Barron’s9 study of necropsy mater-
ial showed that peribiliary infiltration produced
jaundice more frequently than did pressure by
enlarged nodes or masses against the large ducts.
Thus, obstructive jaundice in Hodgkin’s disease
is caused most frequently by intrahepatic in-
volvement, less often by direct involvement of
biliary ducts, and only rarely by compression of
extrahepatic ducts by tumor or involved nodes.

Surgical exploration of our patient, while be
was jaundiced in February 1953, failed to reveal
any nodes or masses compressing the large bile
ducts. A stricture of the common duct was re-
ported, which suggests that the common duct
was involved directly by tumor. External biliary
drainage at that time promptly relieved the jaun-
dice, so intrahepatic involvement probably was
not a factor in the jaundice. Unfortunately, the
extent of hepatic involvement never was deter-
mined in this patient.

The effect of nitrogen mustard on tissue af-
fected by Hodgkin’s disease is not well known
because of lack of suitable material for studv at
proper intervals before and after treatment. The

histologic studies of Spitz10 showed that promi-
nent changes occurred within seven days after
treatment in the 2 cases of Hodgkin’s disease
she studied before and at suitable intervals after
treatment with nitrogen mustard. She noted no
specific changes in the hepatic cells as the re-
sult of use of nitrogen mustard.

In studies on rabbits into which mustard gas
containing radioactive sulfur was injected, Bours-
nell and associates11 noted that the kidneys,
liver, and lungs were the main excretory organs
for nitrogen mustard. Large quantities of this
material were found in the bile and urine during
the first hour of collection after injection. If
great amounts of nitrogen mustard are excreted
in the bile by way of the liver in human beings,
damage to hepatic cells may well occur.

Necrosis of hepatic cells has been reported in
patients with Hodgkin’s disease who received
nitrogen mustard.3,6 However, not all of the
cases in which hepatic necrosis has been found
at necropsy are reported in detail, so it is im-
possible to know whether nitrogen mustard was
given in all cases and if, when given, it was
responsible for the necrosis.

Dameshek and associates3 reported 4 cases
of patients who had Hodgkin’s disease with
hepatomegaly and jaundice to whom nitrogen
mustard was administered. Response to treat-
ment was good in 2, but the condition in the
other 2 became worse. Only 1 of these cases is
reported in detail; the patient concerned did not
have obstructive jaundice and was critically ill
when treatment was undertaken. In their group
of 50 patients to whom nitrogen mustard was
given, Dameshek and associates reported hepatic
necrosis at necropsy in 3. It was considered
likely that the necrosis could be attributed to the
nitrogen mustard.

It is apparent that the causes of jaundice in
Hodgkin’s disease are so many and so varied
that the jaundice alone cannot be the determi-
ning factor in the use or contraindication to the
use of nitrogen mustard. A trial of treatment
with nitrogen mustard appears worthwhile for
those patients who have Hodgkin’s disease
associated with jaundice, particularly if the jaun-
dice is of the obstructive tvpe.

SUMMARY

A report has been given of a case of a patient
with Hodgkin’s disease in whom intermittent
obstructive jaundice developed. The jaundice
was relieved on 4 occasions by use of nitrogen
mustard. The successful administration of nitro-
gen mustard in this case lends support to the
opinion that the presence of jaundice does not

MARCH 1958

101

contraindicate use of nitrogen mustard in Hodg-
kin’s disease.

The current concepts of the mechanisms res-
sponsible for the production of jaundice in Hodg-
kin’s disease are reviewed. It is emphasized that

REFERENCES

1. Minot, G. R., and Isaacs, R.: Lymphoblastoma: aspects con-
cerning abdominal lesions, especially their production of early
symptoms. Am. J. M. Sc. 172:157, 1926.

2. Goldman, L. B.: Hodgkin’s disease: an analysis of 212

cases. J.A.M.A 114:1611, 1940.

3. Dameshek, W., Weisfuse, L., and Stein, T.: Nitrogen mus-
tard therapy in Hodgkin’s disease; analysis of 50 consecutive
cases. Blood 4:338, 1949.

4. Stats, D., Rosenthal, N., and Wasserman, L. R.: Hemo-
lytic anemia associated with malignant diseases. Am. J. Clin.
Path. 17:585, 1947.

5. Lichtman, S. S.: Diseases of Liver, Gallbladder, and Bile

Ducts, 3rd ed. Philadelphia: Lea & Febiger, 1953, vol. 2,
pp. 1079-1080.

6. Beatty, E. C., Jr.: Jaundice in Hodgkin’s disease. Bull. New
York Acad. Med. 30:409, 1954.

intrahcpatic involvement or direct involvement
of the main bile duct in Hodgkin’s disease is
more likely to cause obstructive jaundice than
is pressure or compression of the extrahepatic
bile ducts by enlarged peribiliary nodes or tumor.

7. Pepper, O. H. P.: Hodgkin’s disease with jaundice as an

early symptom; illustrative case. M. Clin. North America
March:’ 1449, 1920.

8. Jackson, H., Jr., and Parker, F., Jr.: Hodgkin’s Disease and
Allied Disorders. New York: Oxford University Press, 1947,
177 pp.

9. Barron, M.: Unique features of Hodgkin’s disease (lympho-
granulomatosis ) : with report of 3 unusual cases and a sum-

mary of 24 cases studied at necropsy. Arch. Path. 2:659,
1926.

10. Spitz, S.: Histological effects of nitrogen mustards on human

tumors and tissues. Cancer 1:383, 1948.

11. Boursnell, J. C., and others: Studies on mustard gas ( pp
dichlorodiethyl sulphide) and some related compounds; fate
of injected mustard gas (containing radioactive sulphur) in
the animal body. Biochem. J. 40:756, 1946.

f

The incidence of gangrene in diabetic persons is related to infection but not
to insulin requirement or known duration of diabetes.

Gangrene is sometimes the presenting symptom with diabetes. Probablv,
a long period of undiagnosed, slight diabetes precedes this manifestation.

Gangrene is often fatal. In some patients, some other manifestation of
generalized atherosclerosis is the immediate cause of death and gangrene is
contributory. Occasionally, patients die of an unrelated disease.

Survival after amputation is longer with diabetic than with nondiabetic
gangrene, since vascular obstruction is less severe in the former group.

Advanced hyalinization of the juxtaglomerular segment of the afferent renal
arterioles probably indicates diabetes or a prediabetic state. This condition is
13 times as frequent in diabetic as in nondiabetic patients. Intracapillary glom-
erulosclerosis, not observed in nondiabetic persons, appears in 48 per cent of
diabetic patients.

Atherosclerotic gangrene is 53 times as frequent in diabetic as in nondia-
betic men over 40 years of age and 71 times as frequent in diabetic as in non-
diabetic women of the same age. In men under 80 years of age, two-thirds of
all instances of atherosclerotic gangrene are associated with diabetes. In wom-
en, approximately 80 per cent of atherosclerotic gangrene results from diabetes.

E. T. Bell, M.D., University of Minnesota, Minneapolis. Am. J. Clin. Path. 28:27-36, 1957.

102

THE JOURNAL-LANCET

Immediate Planning for Definitive Treatment
of Severely Injured Individuals
with Multiple Fractures

GEORGE L. DIXON, M.D.

Tucson, Arizona

It ocgured to us approximately a year ago,
when caring for a patient with multiple in-
juries incurred as a result of a violent accident,
that we were using the same general plan of
treatment that we had used for well over three
decades. This plan consisted of four parts:

1. First aid.

2. General examination and planning for definitive
treatment.

3. The use of consultants.

4. The general management, supervision, total han-
dling of the case by one man.

It further occurred to us that a plan to have
been followed for so many years must have had
some merit, for, judging by the survival rate of
such victims and the percentage of those restored
to full function, the modern medicine of the
middle “20's,” when compared to present knowl-
edge, was as immature as medicine of the middle
“90s” was to medicine of the middle “20’s.”

Bear in mind while reading this paper that
the author is an orthopedist and that the title
is not entirely accurate in stressing multiple
fractures, as there has been gross insult to many
of the soft tissues in accidents of violence. The
survival of the victim and his restoration to
function may depend on the recognition and
treatment of these injuries, as well as treatment
of the fractures. The victim of today has the
additional advantages of:

1. Rapid communication.

2. Rapid transportation.

3. Organized and well equipped emergency rooms in
hospitals with complete equipment.

4. Increased medical knowledge, including specializa-
tion.

5. Modern and present day teamwork within the med-
ical profession.

George l. dixon is a specialist in orthopedic surgenj
with offices in Tucson, Arizona.

Paper presented at the annual meeting of the
American Fracture Association in El Paso, Texas,
October 1, 1957.

Before presenting the plan used today, let us
visualize the victim with multiple serious in-
juries caused by an automobile accident, the
most common accident of violence in this era.
The police officer arrives shortly after the acci-
dent and directs the first aid in addition to his
other duties, using his short-wave radio to call
an ambulance and, on its arrival, he figuratively
heaves a sigh of relief and turns the patient over
to the care of attendants for possible additional
first-aid treatment. The purpose, as in all first
aid, is “to prevent further injury.” The victim is
transported rapidly to an emergency room of the
nearest hospital, where a “glorified” type of first
aid can be practiced because of the organization
and equipment. We use the term “glorified
because all supplies and hospital services are
available. As soon as possible, ambulance at-
tendants and emergency room personnel place
the victim on a wheeled cart on which he may be
treated for many hours or transported to other
parts of the hospital without gross handling. At
this time, the patient is given a complete, rapid,
general examination for total evaluation, and a
working diagnosis can be adequately accomp-
lished and additional special services available
in the hospital can be called upon. In making
this evaluation, we have found it useful to ex-
amine the various bodily systems, consisting of
the nervous, cardiovascular, upper respiratory,
musculoskeletal, and the genitourinary systems,
in order to determine which has been subject to
the greatest trauma and the effect upon the other
systems.

The plan used today has the same principal
parts as it did originally.

1. Under the auspices of the county medical
society, a parent organization of all medicine in
the community, with the aid of the Red Cross,
regular first-aid instruction is given preferably
by a doctor as an instructor to: (a) all police
officers and (b) owners, operators, and attend-
ants of ambulances.

MARCH 1958

103

The latter, by virtue of their occupation, care
for more victims than does a single police officer.

2. Emergency room. Again, under auspices of
the county medical society, the staffs of the var-
ious hospitals are made responsible for the organ-
ization and equipment of their emergency rooms
and hospitals.

a. Glorified first aid.

b. General examination, evaluation, and plan-
ning for definitive treatment of the victim.

Here, it should again be pointed out that with
the victim on a wheeled cart, not only the ex-
amination but many forms of treatment can be
accomplished. Also, when the patient is to be
moved to another part of the hospital, he will
not require further gross handling, and, if he is
to go to his room, arrangements can be made for
certain equipment to be present on his arrival.
If he is to be transferred to an operating room,
personnel and equipment can be made ready,
converting the emergency operating room pro-
cedure to a planned procedure.

3. Consultants. The part played by consultants
in medicine of today does not require explana-
tion, which leads us to a discussion of con-
sultants employed by the physician or surgeon
in charge and their possible abuse of the victim.
In most instances, after the physician or surgeon
in charge chooses a consultant, he must then
decide how soon he should see the patient. Ordi-
narily, a physician’s general knowledge enables
him to administer the preventive and early treat-
ment, but, in some instances, it is best to tele-
phone the consultant, giving him a general pic-
ture of the case, asking him for suggestions for
immediate treatment, and arranging for him to
see the patient. Certainly, in all requests for con-
sultants on accident cases, the man in charge
should be the one to present to them the over-
all picture. The patient may suffer abuse at any
time after the consultants’ arrival, since nothing

contuses any emergency room crew to the detri-
ment of the victim’s welfare more than an ex-
amination and orders given by one or more con-
sultants at the same time. Furthermore, even
after the critical period and later, multiplicity of
orders continues to confuse the personnel and is
detrimental to the patient’s welfare.

4. General management and supervision by
one physician or surgeon. At this point, we have
admitted a very definite need for consultants,
but all of us who limit our practice to one field
of medicine are apt to have a common failing of
“tubal-vision,” and, as a result, easily forget
momentarily the patient as a whole. For that
reason, one physician should supervise the orders
so that they can be timed properly and allow the
victim the physiologic rest necessary for his re-
covery without neglecting any particular injury.
This is more easily arranged if the same team
always works together, but any team can ac-
complish the same objective by using the tele-
phone and considering suggestions made by the
several consultants.

The past medical history and general condi-
tion of the patient just prior to the accident are
quite as important in an accident case as in any
other seriously ill individual, and this information
c^n be gradually acquired from friends, relatives,
and the patient. The cause of the accident and
its degree of violence must also be considered
and can be gained in part from the police officers,
ambulance attendants, others in the accident,
and witnesses, as well as, possibly, the patient.

Presentation of this paper was concluded by
the use of a double screen, and, for each case on
one side of the screen not discussed, the compli-
cations, and list of consultants, the slide gave a
brief history, the multiple diagnoses, the past
medical history, while, on the other side, multiple
plates were used to illustrate interesting ortho-
pedic problems brought out by these cases.

104

THE JOURNAL-LANCET

The Medicinal Treatment of Asthma

J. HARVEY BLACK, M.D.
Dallas, Texas

All physicians regardless of the field of medi-
cine in which they practice, have occasion,
at one time or another, to meet the pressing prob-
lem of offering relief to someone suffering from
severe asthma and for whom help is urgently
needed. I should like to offer some suggestions
which may be of help under those circumstances.

There are many medicinal agents available.
Some are much more effective than others; some
act more rapidly than others; some have fewer
contraindications than others; and some should
not be used at all. Let us run rapidly over the
list.

For the sake of emphasis let me say first that
opiates should not be used in anv form. In my
own experience, I have seen as many deaths
occur from the use of an opiate in the treatment
of the asthmatic paroxysm as I have from the
asthmatic attack itself. There is some argument
as to the mechanism that causes death but none
concerning the fact that it occurs. Many patients
can tolerate an opiate well, but its continued use
in asthmatic patients sooner or later results in
death. This interdiction applies to all opium
derivatives. If an opiate is given, an ampule of
Nalline should be on hand, and the patient
should not be left alone unless someone is avail-
able to administer it in case of necessity. On two
occasions, in the hands of my associate, Nalline
has been lifesaving.

The steroids have been much in the public
eye and have come into general, even indiscrimi-
nate, use. They are used much more often, 1
think, than is desirable. They usually relieve
attacks of asthma which fail to respond to the
usual measures, and, consequently, they can be
of great help in such difficult situations. But, the
steroids or ACTH do not bring relief as rapidly
as epinephrine and should not be used unless and
until the latter has been tried and failed. To my
mind, long continued use of any steroid for the
treatment of asthma is not justified unless all
other measures have failed. I believe the steroids
are only helpful as emegency medications. There
are exceptions, of course, to this rule but they

j. harvey black, a specialist in allergies, maintains
offices in Dallas, Texas.

should be few. We have seen a few patients with
constant asthma that was resistant to all conven-
tional means of relief who could be kept alive
and in comparative comfort with daily doses of a
steroid. Under these circumstances, we feel that
the continued use of these agents is justified.

Epinephrine is still the most valuable drug for
the treatment of asthma. Its action is rapid and,
in most instances, effective. Its side effects are of
little importance. Continued use does not lead to
addiction nor does it damage the cardiovascular
system. It may be used both as a watery solution
and a suspension in oil. In oil, the action is more
prolonged but also slower in its onset so that a
choice should depend upon whether long pro-
tection or rapid relief is most needed. Often, un-
necessarily large doses are given, resulting in
pallor, tachycardia, and tremor. I am convinced
that 0.5 cc. is fully as effective as a larger dose.
Except in grave emergencies, intravenous epine-
phrine is not indicated. If the need should arise,
it may be instilled into the vein a drop at a time
or, better, diluted by saline or glucose solution.
One should be prepared for the fact that even a
single undiluted drop into a vein may precipi-
tate a violent, occipital headache.

Epinephrine in oil is supposed to be absorbed
over a much longer period than the watery solu-
tion, but it should be remembered that it is a sus-
pension in oil and, sometimes, is absorbed more
rapidly than is expected or desired. Since the
dosage employed is usually twice the amount of
the drug in solution, symptoms of overdosage
may occur, consisting of pallor, tachycardia, and
tremor.

The use of epinephrine by inhalation is help-
ful in the patient having recurrent, mild attacks.
It does not control severe attacks, as do hypoder-
mic injections, but for those less severe, it is
quite convenient and can be used promptly in
the beginning of an attack. This is important,
for, with epinephrine as with other forms of
medication, an asthmatic attack can best be con-
trolled by the earliest possible medication.

Norepinephrine (Arterenol) also is produced
by the adrenal medulla. It, too, is a vasoconstric-
tor with little or no effect on cardiac output and
little hyperglycemic action. Commercial epine-

MARCH 1958

105

phrine contains approximately 15 per cent nore-
pinephrine. It is effective in the relief of asthma.
Isopropylarterenol is available as Isuprel, which
may be nsed by inhalation and sublingually and
as Norisodrine, which is used as an inhalant
powder. In a considerable number of patients,
these agents produce so much cardiac stimula-
tion that patients refuse to continue their use.
In those who do not suffer these effects, they may
he effective but seldom provide as much relief as
< Iocs epinephrine when it is administered hypo-
dermically.

Ephedrine has been used for the past thirty
years. It has advantages over epinephrine in that
it may be used orally, as a preventive, and its
action is much more prolonged. Its disadvant-
ages are that it is less potent and that central
stimulation often so disturbs the patient that it
cannot be used. It may be used orally, sub-
cutaneously, or reetallv, alone or, more frequent-
ly, in combination with other drugs. Recephe-
drine, which is racemic ephedrine, is not as effec-
tive as 1-ephedrine, hut it does not produce as
much central stimulation and often can be used
when 1-ephedrine cannot. To retain the effec-
tiveness of ephedrine and avoid its side effects,
many synthetic substances have been made,
such as Neo-Synephrine, Propadrine, Nethamine
and others, all of which are less likely to disturb
the patient but also are less effective.

The xanthine compounds are quite helpful.
Even a cup of hot coffee may give much relief,
though whether this is due to the heat or caffe-
ine is questionable. Theophylline and aminophyl-
line are in quite general use. They may be
administered orally, reetallv, or intravenously.
When injected into the muscle, they cause such
severe pain that, in my opinion, they should
never be so used. Even a little leakage from an
intravenous injection is very painful and should
be carefully avoided. A rectal suppository some-
times is almost as effective as an intravenous in-
jection. The intravenous injection of as much as
0.5 gm. often relieves attacks that are resistant to
epinephrine. Some severe reactions and a few
deaths have been reported from the intravenous
use of aminophvlline, but I have not seen one.
Very slow injection, taking at least five minutes
for the introduction of 0.5 gm„ has not produced
any reactions in our experience. Enteric-coated
tablets taken at bedtime often protect patients
through the latter part of the night, which is the
time when an asthmatic attack usually occurs.
The uncoated tablet or the suppository taken at
bedtime does not remain effective until the early
morning hours, which is the time when protec-
tion is needed most.

Potassium iodide, an old and valuable remedy,
is not of service in the relief of the immediate
asthmatic attack but, over a period of days, may
produce a more liquid sputum and, by lessening
the severity of the cough, it prevents the develop-
ment of severe dyspnea.

Recently trypsin and Alevaire (a detergent
compound ) have been used by inhalation and
seem to be helpful in the presence of much tena-
cious mucus. Personally, I still wonder if they
are much more effective than the iodide. Inci-
dentally, since the iodide is absorbed so rapidly
when given by mouth that it is detected in the
saliva in thirty minutes, intravenous injections
are seldom needed. It should he kept in mind
that sooner or later an acneform eruption or
gastric distress may develop in some patients
from the iodide. Rarely, a parotid swelling or
edema of the nasal mucosa with rhinorrhea de-
velops.

Glucose and water are lost rapidly in a severe
asthmatic attack and should be replaced. Prob-
ably nothing helps a patient in status asthmaticus
more than a considerable amount of glucose and
water. If he is able to swallow and to retain
fluid, it may be given by mouth, and corn syrup
may be used. Sweetened fruit juices given fre-
quently can be used to advantage.

1 am convinced that oxygen is not needed in
the treatment of asthma as often as it is used.
If the patient is in status asthmaticus and is
cyanotic, oxygen may he helpful. It should be
remembered that in the acute attack, the patient’s
difficulty is not due to the lack of oxygen in the
respired air but to the narrowed tube through
which he tries to breathe. If the lumen of the
tube can be increased by medication, he usuallv
has no difficulty in acquiring as much oxygen as
he needs. In instances in which medication is
not producing the desired result and cyanosis has
ensued, oxygen may be helpful. Even in such
cases, it should be watched carefully if it is con-
tinued for some time, since it is not without
danger. These patients may show hypoxemia and
an increased pC02 and lowered pH. With the
loss of the drive for respiration due to the hv-
poxia and a possible loss of sensitivity of the
medullary centers for pCCV, respiratory failure
may occur. Continuous administration may cause
pulmonary irritation, stupor, coma, and con-
vulsions.

The antihistaminic drugs are seldom of much
help in an asthmatic attack. Why they should he
helpful in the treatment of hay fever and of
relatively little value in asthma, we do not know.
That this is not generally recognized is shown
by the fact that a large per cent of the asthmatic

106

THE JOURNAL-LANCET

patients referred to us have had no previous
medication other than astihistaminic drugs.

Another practice with which I do not agree
is the general use of antibiotics in asthmatic
patients with no evidence of infection. Patients
with asthma may also have a respiratory in-
fection for which an antibiotic may be indicated,
but asthma is not an infectious disease and is
not favorably influenced by antibiotics except
when an intercurrent infection is present.

Piromen is a suspension of a sterile bacterial
polysaccharide which, in enormous dilution, has
been recommended for the relief of asthma. We
have not found it of value.

For some obscure reason, aspirin occasionally

relieves asthma. Five grains are sometimes as
effective as 0.5 ce. of epinephrine. Since some
persons are dangerously sensitive to aspirin, it
should not be prescribed until its safety has been
established.

Alcohol has been effective in some patients
but many are made worse by it.

Arsenic has been used in the celebrated “Gay
formula and seems to be of some help if con-
tinued over considerable time. It is, of course,
a dangerous drug if used over long periods.

None of our medicinal agents cures asthma,
but, if used to best advantage, the physician can
relieve much suffering and earn the gratitude of
distressed and frightened patients.

In recent years, the incidence of paralytic poliomyelitis in adults has in-
creased. Because of this increase and because poliomyelitis tends to lie more
severe in older patients, immunization of adults is as essential as immunization
of children.

Pure spinal poliomyelitis is the most common form of paralytic poliomyelitis
in all age groups. Incidence of bulbospinal poliomyelitis increases with age,
being about 7 per cent in children under 5 years of age and about 40 per cent
in patients over 40 years old.

Extent of involvement with spinal paralysis also varies with age. In pa-
tients less than 5 years of age, monoplegia is most common; monoplegia and
paraplegia are most frequent in patients 6 to 15 years old, while quadriplegia
occurs in about one-half of patients over 15 years of age. In patients with
monoplegia, the left side is more often affected than the right.

Bladder paralysis is more common in adults than in children, affecting one-
third or more of patients 16 years of age or older. Respiratory muscle paralysis
is 9 times as frequent in adults as in children. Mortality from paralytic polio-
myelitis also increases with age. About 3.1 per cent of patients under 16 years
of age, 8.5 per cent of those 16 to 30 years old, and 29.6 per cent of those
40 vears of age or older die of the disease.

Sex also influences manifestations of poliomyelitis. More male than female
children have paralytic disease, but adult women are affected more often than
adult men. Disease tends to be more severe in female children and in adult
males. Quadriplegia, respiratory paralysis, and death are more common among
adult men than among women. Men over 40 years old appear to be most
susceptible to severe paralytic poliomyelitis.

Louis Weinstein, M.D., Boston University, New England J. Med. 257:47-52, 1957.

MARCH 1958

107

Health of the American Indians

HERBERT A. HUDGINS, M.D.
Aberdeen, South Dakota

On July 1, 1955, the Public Health Service,
Department of Health, Education, and Wel-
fare, took over administration of the medical
program for Indians and Alaska natives. This
responsibility was transferred from the Bureau
of Indian Affairs, Department of the Interior,
under the terms of Public Law 568, 83rd Con-
gress, 2nd Session. To conduct this program, the
Public Health Service organized the Division of
Indian Health as part of its Bureau of Medical
Services.

The provision of health services to the Indians
has long been recognized as a federal obligation.
Historically, this responsibility dates from the
time the Indians were located on reservations
by the federal government and were under the
jurisdiction of the War Department. In 1849, the
Department of the Interior was made responsible
for Indian affairs, and later a program for med-
ical care and health services was developed.
In later years, the technical leadership for the
health program within the Department of In-
terior was rendered by officers assigned from
the Public Health Service. The existence and
continuity of this knowledgeable leadership since
the transfer of responsibility on July 1, 1955, have
resulted in the maximum increase of services
compatible with available funds.

The program of the Division of Indian Health
is administered through 6 area offices in Port-
land, Oregon; Aberdeen, South Dakota; Okla-
homa City, Oklahoma; Albuquerque, New Mex-
ico; Phoenix, Arizona; and Anchorage, Alaska.
Services are provided for approximately 315,000
Indians living on about 250 reservations in 24
states and approximately 35,000 natives in the
Territory of Alaska. Excluded are sizable num-
bers of Indians living in the East whose care is
not a responsibility of the federal government.
Also excluded are those Indians who have volun-
tarily moved away from their reservations, most-
ly to the larger cities, and beyond the effective
reach of Division of Indian Health facilities.

Herbert a. hudgins is a medical director in the Unit-
ed States Public Health Service and area medical of-
ficer of the Division of Indian Health, United States
Public Health Service, Aberdeen, South Dakota.

The health status of the American Indian is,
in general, that of any underprivileged group.
The high disease indices always quoted pertain
to those remaining on reservations and not to the
thousands who have become a part of the dom-
inant culture. There appears to be no predilec-
tion for certain diseases, but rather we observe
the high rates in diseases identified with low
economic resources. Those of us in the Indian
health program feel that the socio-economic dis-
advantages prevalent among the Indians must
be solved concomitantly with any marked im-
provement in their health status. In spite of the
deficiency in such necessities as housing, cloth-
ing, food, transportation, and so forth, we find
real concern among the Indians in regard to
health matters and an increasing acceptance of
recognized health procedures.

» Recognition of the high incidence of prevent-
able diseases is given in the 1956 annual report
of the Department of Health, Education, and
Welfare, which reads, “Historically, our Indians
and Alaska natives have been isolated both geo-
graphically and culturally from the mainstream
of progress that brought health records to each
succeeding generation of Americans. The health
needs of these people are critical. Their average
age at time of death, for example, is 39 — com-
pared with 60 for the general population.

“Most of their illnesses are tragically due to
causes that can be prevented. For this reason,
the Public Health Service has accelerated its
program of disease prevention. More than $4.3
million was spent in this effort during the year,
and more than 500 of the 4,150 Indian health
staff were engaged in preventive health activi-
ties.”

The Public Health Service realizes that any
health program of lasting value must be devel-
oped with the people concerned. Accordingly,
at the reservation level, every effort is made to
encourage self-reliance and independence on the
part of the Indian people, and their participation
is sought in planning health activities. The speed
and success in this cooperative planning natural-
ly vary as they would in any population group.
The Indians are also assisted in making use of
state and local services of health, vocational re-

108

THE JOURNAL-LANCET

habilitation, and crippled children’s agencies.

At the national level, judgment of the Indians
and other authorities is obtained through an Ad-
visory Committee on Indian Health named by
the Surgeon General in May 1956. This com-
mittee, with members representing medicine,
science, law, education, journalism, and the In-
dian peoples, is aiding in the development of
policies to improve health services to the Indians.

The goal is to develop a total health program,
with equal importance given to the two major
phases — preventive and curative. This will he
obtained through direct operation by the Public
Health Service when necessary or bv contract
services where such are possible and feasible.
Full integration of both phases is also a goal as
each supplements the effectiveness of the other.

In compliance with a request of the House
Committee on Appropriations of the 84th Con-
gress, 1st session, a comprehensive survey of
Indian health needs was made. This report con-
tains the following description of some communi-
ties among Northern Plains Indians that must be
changed to gain the optimum in health progress.

ECONOMIC RESOURCES

“With the exception of one small reservation,
both land resources and employment opportuni-
ties were considered to be wholly inadequate to
support the population. On the largest reserva-
tion in the area, it was estimated that not more
than a third of the present population could be
supported from reservation resources even as-
suming more efficient use. Far less than this
number were being supported at the time of the
survey. On another reservation, approximately
5,000 Indians lived on land which could not
support more than a tenth of that number. On
a number of reservations, even the inadequate
amounts of land available were not being used
fully by Indians, and the trend seemed to be
toward decreasing use. The sale of land had
been increasing.”

WATER SUPPLY

“The community provides itself with water from
four wells and three sunken barrels placed in
excavations in an intermittent stream bed. The
only well that approaches sanitary approval is
that at the school. An outside faucet on the
pump house is maintained for the Indians to use
as they wish. Fifty per cent of the households
obtain their water here. Twenty per cent haul
their water by automobiles, 20 per cent by wag-
on, and 60 per cent by hand. Milk cans, buckets,
and barrels are used — none of which even ap-
proaches sanitary standards. Hauling distances

range from 50 to 700 yd., averaging about 400
yd. No disinfection of any kind is practiced.”

EXCRETA DISPOSAL AND FLIES

“In the entire community (excluding the school),
there is only one privy that meets sanitary stand-
ards. Every one of the others needs complete re-
habilitation. Five families have no privies of
their own. They share the facilities of neighbors.
The most bothersome insects reported are Hies,
mosquitoes, and fleas — mostly fleas. Screens are
absent from more than 60 per cent of the houses,
and the unprotected outdoor cooking, eating,
and sleeping in the summer provide these pests
with abundant fresh food and human prey.”

HOUSING

“Slightly over 75 per cent of the houses are of
mud-caulked logs and earth covered roofs. About
20 per cent are of frame construction, 1 of these
being of a log-frame combination. The remain-
ing 5 per cent are classified as shacks, being
thrown together with scraps of building material
of any kind. The largest number of persons per
dwelling is 11, the minimum 1, the average
about 3. Although the average may seem low,
the small size of the homes, in general, causes
overcrowding. Slightly over 40 per cent have
only 2 rooms, this being the maximum number
of rooms in any habitation.”

Such adverse environmental conditions over a
period of several generations can well account
for the facts that 33 per cent of the deaths
among Indians occur before the fifth year of life,
whereas only 8 per cent of the deaths in the gen-
eral population are in this age group; that the
Indian death rate from influenza and pneumonia
is nearly 4 times that of the general population;
that the death rate for tuberculosis is 5 times
greater, and for enteric diseases 10 times greater
than corresponding death rates in the population
as a whole.

There are approximately 36,900 Public Health
Service Indian beneficiaries in the 2 Dakotas and
Nebraska. A review of certain communicable
disease rates per 100,000 population reveals:

1952

1953

1954

1955

1956

Tuberculosis, all forms

609.4

584.2

593.9

663.9

634.2

Influenza

203.1

3,313.8

2,661.1

81.3

46.1

Pneumonia

817.7

1.283.2

2,095.2

1,512.2

2,192.4

Diphtheria

13.0

2.6

2.8

10.8

5.4

Whooping cough

67.7

15.3

207.3

192.4

723.6

Poliomyelitis

26.0

25.5

2.8

8.1

5.4

Measles

658.9

377.6

596.6

514.9

1,124.7

Gonorrhea

466.1

607.1

753.5

929.5

916.0

Syphilis and sequelae

299.5

247.4

252.1

409.2

238.5

Typhoid fever

5.2

10.2

8.4

19.0

2.7

Dysentery, all forms

875.0

637.8

92.4

393.0

94.9

MARCH 1958

109

In this same population group and for the
same years, the leading causes of death per
100,000 population were:

1952

1953

1954

1955

1 956

1. Heart diseases

181.8

145.4

137.3

86.7

149.1

2. Accidents, total

114.3

68.9

75.6

67.7

119.3

3. Tuberculosis, all forms

143.7

89.3

78.4

48.8

62.3

4. Symptoms,

senility, ill-defined

129.0

68.9

42.0

75.9

84.0

5. Malignant neoplasms

90.9

48.5

72.8

43.4

56.9

6. Vascular lesions affecting
central nervous system

55.7

30.6

36.4

46.1

35.2

7. Certain diseases peculiar
to early infancy and
immaturity unqualified

29.3

10.2

33.6

29.8

43.4

S. Gastritis, duodenitis,

enteritis, and colitis

26.4

23.0

22.4

35.2

27.1

9. Birth injuries, postnatal
asphyxia, atelectasis

29.3

30.6

14.0

32.5

13.6

10. Infections of newborn

20.5

17.9

22.4

21.7

16.3

The numerical standing of the preceding fig-
ures is based upon the five-year average.

In spite of the adverse socio-economic condi-
tions under which most of the Northern Plains
Indians live, the Public Health Service has found
a great deal of initiative among the Indian
groups in working toward a solution of their
health problems. Of the total of 36,900 bene-
ficiaries, 30,900 are served by directly operated

Public Health Service hospitals. The use of serv-
ices by this latter group has remained about con-
stant during the period fiscal year 1952 through
1956 but showed a pronounced increase in 1957.

1952

1953

1954

1955

1956

1957

8 PHS operated Indian
general hospitals

6,245

6,914

6,290

6,010

6,808

8,522

1 PHS operated

tuberculosis hospital

189

204

298

287

462

410

In this same group, outpatient therapeutic vis-
its in 1955 totaled 62,896; in 1956, 74,824; and
in 1957, 79,897. Outpatient preventive visits in
1955 totaled 11,624; in 1956, 16,694; and in 1957,
31,942.

In conclusion, one can say that the Northern
Plains Indians have too high an incidence of
preventable diseases, that they live under ad-
verse socio-economic conditions, but that thev
do use medical services and have an interest in
participating in the development of a more ef-
fective health program.

For those interested in Indian health in more detail,
reference is made to: Health Service for American In-
dians, Public Health Service Publication No. 531. For
sale by the Superintendent of Documents, U. S. Gov-
ernment Printing Office, Washington 25, D. C. Price
$1.75.

»

Lack of medical knowledge is less to blame for errors in diagnosis than lack
of judgment, alertness, and thoroughness. The factors most commonly respon-
sible for avoidable diagnostic errors are, in order of frequency: (1) failure

to carry out or repeat necessarv procedures; (2) neglect of symptoms or signs;
(3) failure to account for abnormal laboratory, electrocardiographic, or roent-
genographic reports; (4) attributing symptoms to the wrong condition, usually
a previously diagnosed illness; and (5) failure to make admission screening
tests.

In almost half of misdiagnoses, the history is not obtained from the patient
himself, usually because of alcoholism, confusion, weakness, shock, coma, or
aphasia. Alcoholism is implicated in 28 per cent of diagnostic errors; mislead-
ing normal roentgenograms in 12 per cent.

Infections, particularly bacterial pneumonia, meningitis, and bacterial en-
docarditis, are most frequently overlooked. Neoplasms, especially of the liver
and brain, are almost as frequently missed. Abdominal disorders requiring sur-
gery, especially those due to duodenal ulcer, and cardiovascular accidents are
common sources of error.

A studv of 1,106 autopsies showed that diagnoses were incorrect in 6
per cent.

Robert II. Gruver, M.D., and Edward D. Fheis, M IL, Veterans Administration Hospital, Wash-
ington, D.C. Ann. Int. Med. 47:108-120, 1957.

110

THE JOURNAL-LANCET

CtiHCCt iVlitorial

Health Supervision of Children

\ campaign to encourage regular periodic
health examinations of children has been
instituted by the National Congress of Parents
and Teachers. This has been recommended by
Dr. Henry F. Helmholz, national chairman of
the Committee on Health of the Parent-Teachers
Association, and an advisory committee repre-
senting 20 organizations concerned with child
health. In an editorial in the Journal of the
American Medical Association on May 4, 1957,
Dr. Helmholz outlines the recommendations
which have been made. He tells how this is an
outgrowth of the “summer roundup, which was
begun by the National Congress of Parents and
Teachers in 1925, to have all children receive a
medical examination before entering the first
grade in school.

The present recommendation is to extend this
I medical supervision to include regular yearly
health appraisal of children through the grades
and high school. This examination is to be per-
formed by the physician and dentist who nor-
mally serve the child or family. Continuing
health supervision is also recommended for in-
fants and preschool children. The latter would,
of course, be done more frequently than at yearly
intervals. Immunizations should be carried out
and booster shots given as needed. If symptoms
or screening tests indicate anything suspicious of
visual or hearing defects, appropriate consulta-
tion should be obtained. Any family or personal
emotional problems should be discussed with
the pediatrician or general practitioner who
should appraise the case and arrange for pscho-
logic or psychiatric care if a case should require
this type of evaluation or treatment. Diet and
vitamins are to be discussed at these examina-
tions, together with a brief discussion of normal
physical and mental growth and behavior. In
this day of television and many other distracting
influences, it is always well to mention the desir-
ability of limiting the time allowed for such
activities, together with a recommendation as to
the amount of rest needed at different age levels.

Officials of the P.T.A. throughout the country
have been notified of the recommendations of
the national organization and have been asked to
support such health supervision. Physicians con-
cerned with child care in each community are
encouraged to take the initiative in instigating
such a program in case it has not already been
done by the P.T.A. Physicians and the local
P.T.A. organization can work in cooperation with
each other to good advantage. The importance
of having this type of examination done by a
private practitioner whenever possible should be
emphasized to the P.T.A. members. A misunder-
standing in our local community in past years
led the P.T.A. to mistakingly inform parents that
the “summer roundup” examination had to be
done by the city health officer rather than the
family pediatrician or general practitioner. That
situation has since been corrected, but closer
cooperation between interested parties could
have prevented such a misunderstanding. The
health officer and public health nurse are an
integral part of the over-all program of child
health, but their services should be reserved for
cases in which financial or other reasons make
private care impossible. I am sure that most
health officers would agree that they cannot pos-
siblv examine all school children adequately and
that this should be done by the family’s own
physician wherever possible.

In conclusion, the national Parent-Teachers
Association stands ready to cooperate with local
physicians and their state and county medical
societies to promote better and more regular
health care of children. As physicians, it is our
responsibility to accept this challenge and offer
our full support and cooperation, recognizing
that this is simply putting emphasis on a practice
which most physicians have been carrying out as
a matter of course.

Laurence G. Pray, M.D.

Fargo, North Dakota

North Dakota State Chairman,

American Academy of Pediatrics

MARCH 1958

111

Etiologic Factors in Renal Lithiasis,
by Arthur J. Butt, 1956. Spring-
field, Illinois: Charles C Thomas,
20 contributors, 18 chapters, 387
pages. $12.50.

This book is a resume of the etio-
logic factors in renal lithiasis. The
historic review and the discussion
of the upper urinary tract obstruc-
tion and stasis are excellent. The
remaining 16 chapters deal with
anatomy and the metabolic, geo-
graphic, chemical, and infectious
theories in the production of stone.
There are sufficient illustrations of
good quality. Several minor typo-
graphical errors are present. The
bibliography is adequate. However,
this text is of value primarily to
those engaged in the investigation
of renal lithiasis.

M. P. Reiser, M.D.

•

Atomic Energy in Medicine, by K.
E. Halnan, M.D. General editor,
1). Wraoge Morley, 1957. New
York: Philosophical Library. 15 s.
This very readable book of 150
pages accomplishes to a remarkable
degree what its author indicates in
the foreword that he hopes it will
do; namely, to provide an account
of atomic energy in medicine intel-
ligible for persons without intensive
prior knowledge either of physics or
of medicine. It provides an ade-
quate account of the historic de-
velopment and a simplified state-
ment of the present status of knowl-
edge of atomic physics, which can
be verv valuable to physicians whose
formal education was completed
before 1940 and, therefore, did not
include much modern atomic theo-
ry. The book also presents a very
interesting treatment of the rationale
of the use of isotopic tracers in med-
ical research and diagnostic prob-
lems. It uses illustrative instances
to elucidate principles, rather than
attempting an exhaustive factual
treatment of the subject. An un-
usual feature of the book is a final
chapter on The Future. In it, the
author describes some newer re-
search approaches that have not as
yet led to anv useful results, but
which seem to him to hold prom-
ise. For example, “neutron-capture
therapy,” in which slow neutrons
which themselves have little biologic-
effect are “captured” with subse-
quent release of alpha rays of high
biologic activity by elements which
can be highly concentrated in ma-
lignant cells by one or another
method. Another new line of ap-
proach is through radiosensitizers of

which several types are known. The
discovery of such substances which
would be selectively concentrated
in malignant cells would provide
another possible approach to cancer
therapy. The author also predicts
great increases in the use of tracer
methods in medical diagnosis. In
these predictions, he stands on firm
ground because these methods are
already standard research labora-
tory procedures, and it is a virtual
certainty that a quarter of a cen-
tury hence they will be routine hos-
pital laboratory methods.

M. B. Visscher, M.D.

Clinical Pathology Data, by C. J.
Dickinson, B.S., B.M., M.R.C.P.
ed. 2, 1957. Springfield, Illinois:
Charles C Thomtis, 91 pages.
$4.00.

This is not a textbook but a refer-
ence book listing the normal and
pathologic alterations in all types of
clinical laboratory procedures. The
book is set up in tabular form and
covers all aspects of clinical pathol-
ogy, including physical properties of
blood and plasma, tests of blood
coagulation, red and white cell
measurements, blood chemistry, cere-
brospinal fluid, urine, feces, porphy-
rin metabolism, serologic tests for
syphilis, and adrenal, liver, and renal
function tests. The volume will be
of value to the medical student and
to many general practitioners whose
association with some of the tests is
sufficiently infrequent to necessitate
a review of normal and pathologic-
values.

John I. Coe, M.D.

•

Bedside Diagnosis, by Charles
Seward, M.D., F.R.C.P., ed. 4,
1957. Baltimore: Williams and
Wilkins Co., 420 pages. $5.00.
This handy little volume is written
for the physician who desires a
ready source of recall. Division
into 24 chapters is made in order
to consider prominent symptoms and
signs. There is a chapter on psy-
chogenic symptoms and six chapters

on pain, including one on some gen-
eral considerations. Chapters are
included on hematemesis, hematuria,
hemoptysis, and hemorrhagic dis-
eases. The character of approach to
each grouping might be illustrated
by chapter 16 on dyspnoea, cover-
ing 22 pages and divided into phys-
iology, the diagnostic approach,
causes of respiratory tract and lung
diseases, cardiovascular lung states,
blood states, and causes of central
nervous system diseases. The psy-
chogenic causes are listed as hys-
teria and effort syndrome. Chapter
17 considers tachycardia, but the
reviewer could find nothing on bra-
dycardia. Normal values, found in
chapter 24, are not covered as ex-
tensively as is the case in most
American hospitals. The author does
not attempt to give attention to spe-
cific disease per se but only to the
signs and symptoms pointing to
them. The work is rather brief and
tends toward minimal rather than
to extensive discussion. For this rea-
son, it should be of value to the
“busy physician” whose time for
study is limited.

S. Marx White, M.D.

•

The S' alien! Points and the Value of
Venous Angiocardiography in the
Diagnoses of the Cyanotic types of
Congenital Malformations of the
Heart, by Benjamin M. Gasul,
M.D., Gershon Hait, M.D., and
Egbert H. Fell, M.D., 1957.
Springfield, Illinois: Charles C

Thomas, 80 pages. $3.50.

This text presents the results of the
studies of 421 venous angiocardio-
grams without the use of information
from the history, physical, fluoro-
scopic, roentgenologic, electrocardio-
graphic, cardiac catheterization, or
autopsy findings. Diagnosis was
based on angiocardiographic findings
and the knowledge that the patients
were cyanotic.

On the basis of the results of these
studies, patients with cyanotic con-
genital heart disease were divided
into 4 entities: group I, entities in
which diagnosis can almost always
be made by proper interpretation of
technically good angiocardiograms,
group II. entities in which diagnosis
can usually be made; group III, en-
tities in which diagnosis usually can-
not be made; and group IV. entities
which always require additional
studies.

As the authors state, “this manu-
script represents only a summary of
the basic findings of the most im-

( Continued on page 26A )

112

THE JOURNAL-LANCET

“an ideal compound

for use in common
urinary tract infections .”*

Azo Gantrisin provided “prompt and effective clearing of
organisms and pyuria”* plus “dramatic relief of bladder and
urethral symptoms”* in 221 (97%) of 228 patients with
urinary tract infections.

Azo Gantrisin is particularly useful in the treatment of cystitis,
urethritis and prostatitis. It is equally valuable following uro-
logic surgery, cystoscopy and catheterization because it pro-
vides effective antibacterial action plus prompt pain relief.

AZO GANTRISIN®— 500 mg Gantrisin (brand of sulfisoxazole) plus
50 mg phenylazo-diamino-pyridine HC1

*F. K. Garvey and J. M. Lancaster, North Carolina M. J., IS: 78, 1957.

AZO GANTRISIN hoc.

HOFFMANN-LA ROCHE INC • NUTLEY 10 • NEW JERSEY
ORIGINAL RESEARCH IN MEDICINE AND CHEMISTRY

25A

BOOK REVIEWS

(Continued from page 112)
portant types of congenital malfor-
illations of the heart. ’ No other in-
formation, such as that obtained
from electrocardiograms, is included.

Ten basic malformations are pre-
sented with excellent, concise sum-
maries of gross pathology, hemody-
namics, and salient angiocardio-
graphic features. Diagrams and
photographs are very clear and in-
structive. Thus, one purpose of this
book, “to bring out the salient points
in the angiocardiographic diagnosis
of the various cyanotic types of con-
genital malformations of the heart.”
is well accomplished. The overlong
title could well be shortened to
“Handbook of Angiocardiography in
Cyanotic Congenital Heart Disease.”

The other purpose of this text, “to
establish the value of angiocardio-
graphy as a diagnostic tool tor these
entities,” confirms the experience of
various cardiac centers where the
use of angiocardiography in right to
left shunts is nearly routine. How-
ever, the history, physical examina-
tion, roentgenograms, fluoroscopy,
electrocardiograms, and physiologic
studies often are equally important
considerations. Thus, angiocardio-
graphy will rarely be used as a

“separate laboratory tool” as it is in
this study.

The percentages of correct diag-
noses from the studies of angio-
cardiograms alone are excellent,
especially in group I. It is feasible
that biplane angiocardiography at 6
to 12 frames per second will en-
hance the number of correct diag-
noses in all groups.

Since some centers are performing
selective angiocardiography with
mild sedation and without anesthesia,
it is likely that correct diagnoses will
be further increased with very little
added risk to the patient. This should
be especially true in groups III and
IV.

This handy, concise study should
be of very real value to the student
of congenital heart disease.

John P. Veit, M.D.

Psychiatric Education and Progress,
by John C. Whitehorn, M. D.,
1957. Springfield, Illinois: Charles
C Thomas, 45 pages. $1.75.

This small book contains the 1955
Salmon Lectures of the New York
Academy of Medicine. Doctor White-
horn, in his well earned capacity as
spokesman for the psychiatric pro-
fession, takes a critical, although

temperate, look at the present status
of postgraduate education for the
specialty of psychiatry. In approxi-
mately forty minutes reading time,
a remarkably clear opinion can be
obtained of the past and present
state of things in this field. While
acknowledging progress, he wisely
points to the numerous problems
ahead with particular reference to
psychoanalysis and to psychiatric re-
search and training for it. Because
of the phenomenal impact the men-
tal sciences have started to make on
medical education in general, these
lectures should be read by anyone
interested in this topic.

Donald W. Hastings, M.D.

•

The Chronically 111, by Joseph Fox,
1957. New York: Philosophical
Library, Inc., 229 pages. $3.95.
Joseph Fox is the executive director
of the Home for the Chronic Sick in
Irvington, New Jersey. He has writ-
ten a book of much interest to the
physician, the social worker, the
hospital administrator, and to people
interested in labor and management.
There is much valuable information
on rehabilitation and the social prob-
lems of the chronically ill.

Walter C. Aivarez, M.D.

for the peak of analgesic efficiency

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‘Subject to Federal narcotic regulations
Dilaudid®, E. Bilhuber, Inc.

2fiA

SERVING THE MEDICAL PROFESSION OF MINNESOTA,
NORTH DAKOTA, SOUTH DAKOTA AND MONTANA

FOREWORD

Another series of papers of special interest to those interested in the control of
tuberculosis and related conditions are appearing this spring in the Journal-
Lancet. The distinguished Wisconsinite, Dr. William S. Middleton, who now
heads the Medical Division of the Veterans Administration, emphasizes the point
recognized since ancient times that even today the personal relationship between
patient and physician plays a verv important role in the recovery of the patient
in such diseases as tuberculosis where specific drugs are available. The appro-
priate title is “Not by Bread Alone.”

The difficulties of tuberculosis eradication among human beings will be evi-
dent from the paper by the veterinarian. Dr. Paul S. Dodd of Illinois, on the
tuberculin test as it applies both to use among cattle and in human beings. In
some states, there is evidence of slight loss of ground in the bovine tuberculosis
eradication program, which theoretically would seem so easv to bring to a suc-
cessful conclusion.

There is increasing interest in the problem of radiation effects throughout this
country and, indeed, throughout the entire world, as evidenced bv recent corres-
pondence I have had from all corners of the globe. The paper on this subject by
Doctors Marvin, Loken, and Mosser, Department of Radiology, University of
Minnesota School of Medicine will be of special interest. Although further data
may cause some revamping of our current thinking, it would appear that the
radiation dosage from the ordinary Tlx 17-in. film, or even from taking a photo-
fluorograph, is so low that the possibility of genetic mutations of any significance
is remote. This probably also applies with regard to possible adverse effects due
to the direct radiation itself. These comments, of course, are with the assumption
that the machines are properly equipped with cones and filters to eliminate any
unnecessary stray radiation, have been checked by trained x-ray technicians, and
are being operated by trained personnel who are aware of hazards of radiation.
The current concern with regard to this problem does mean, however, that care-
ful records must be kept to determine the fruitfulness of chest x-ray screening of
various population groups which do not yield a significant number of new cases
of tuberculosis and other chest pathology and with priority given to the more
fruitful groups.

Finally, a tribute will appear to one of the pioneers in the voluntary tubercu-
losis field, Dr. Edward A. Meyerding, who is completing this spring thirty-four
years as the chief executive of the Minnesota Tuberculosis and Health Associa-
tion. The manv readers who have known him will join with Dr. Myers in express-
ing appreciation to Dr. Meverding for his many years of devoted service and in
extending him all good wishes for the future.

James E. Perkins, M.D.,

Managing Director ,

National Tuberculosis Association

Ionizing Radiation in Medicine

A Useful Tool and a Hazard

JAMES F. MARVIN, Ph.D., MERLE K. LOKEN, Ph D., and
DONN G. MOSSER, M.D.

Minneapolis, Minnesota

The advent of the atomic age with its mani-
fold increase in resources relating to ionizing
radiations has made it necessary to re-evaloate
the uses of radiations from all sources— x-rays, ra-
dium, radioisotopes, and atomic energy. This has
required a review of the usefulness versus exist-
ing or potential hazards of radiations in medi-
cine, dentistry, industrial development of atomic
power, and weapon testing programs. When
these uses of ionizing radiations were first eval-
uated, statements appeared to the effect that no
radiation hazard problem existed. The pendu-
lum of thought has now swung in the other
direction with its statements that fallout is peril-
ing all future generations, medical x-rays are
producing genetic damage, chest x-rays for tu-
berculosis case finding are extremely dangerous,
and that x-ray shoe-fitting machines are injuring
our children.

We cannot accept without proper interpreta-
tion either the statement that no radiation haz-
ards exist or the hysteria concomitant with theo-
ries that ionizing radiations have no place in our
societv. We are now in the atomic age and are
utilizing the increased resources with a limited
increase in radiation burden. It is not possible
to outlaw the use of atomic energy and all other
sources of ionizing radiations. We must recog-
nize that man cannot have multiple radiation
histories, so that any activity utilizing ionizing
radiations which increases the radiation exposure
to man will have repercussions on all other uses
of such radiation. All sources of ionizing radia-
tion thus relate to the present and future gener-

james f. marvin is associate professor of radiology
at the U niversity of Minnesota, merle k. token is
assistant j)rofessor of radiology at the University.
donn g. mosser is associate professor of radiology
and director of radiation therapy at the University.

Presented in part at district medical meetings in
North Dakota and at Concordia College, Moorhead,
Minnesota, sponsored by North Dakota Tuberculosis
and Health Association.

ations of man. Evaluation of the radiation haz-
ard must also include the problem of the health
and well-being of the individual, as well as ge-
netic considerations relating mankind’s future.

Anv regulations, code, or legislation adopted
for control of the radiation hazard cannot neglect
any possible sources of ionizing radiations. Safe
rules of conduct must include: (1) medical and
dental x-rays, radium, and radioisotopes (now
used much more generally than in the past) and
radiations for industrial purposes insofar as
these contribute to the irradiation of man, (2)
devices such as shoe-fitting Huoroscopes, tele-
vision, and electron microscopes, which may be
sources of ionizing radiation, and (3) atomic
energy for research, weapon testing, or power
( including the mammoth radioactive waste dis-
posal program).

BACKGROUND OR UNCONTROLLABLE RADIATION

All of us continuously receive radiation, termed
background or unavoidable radiation, from cos-
mic rays descending upon us from outer space
and from natural radioctivity in the earth, in our
building materials, and in our bodies. Fallout
from atomic weapon testing and contamination
from the use of radioactive materials may in-
crease the background or unavoidable radiation
in a particular area to such an extent as to be
considered dangerous.

Radiation exposure of an individual may origi-
nate from both external and internal sources. In
most instances, exposure from external sources,
principally x- and gamma rays, constitutes the
greater hazard. Radioactive materials contained
within the body constitute a greater hazard than
when they are external sources because of the
continuous irradiation of tissues surrounding
them. Some of the radiations emitted by radio-
active materials cannot penetrate sufficients to
be as serious a hazard as external sources but
will be absorbed in vital tissues when the mater-
ials are internal sources. Also, some radioactive
materials when taken internally are deposited

114

THE JOURNAL-LANCET

permanently in the bone as radium226 or stron-
tium90.

The problems associated with the weapon test-
ing programs of both the United States and
Russia can be appreciated if one considers the
reports which indicate seasonal and generally
increasing levels of radioactivity in our rainfall
and surface waters and reports which indicate
generally rising levels of strontium90 in bones
as found at autopsy. The problems associated
with increasing utilization of atomic energy for
power purposes can also be appreciated if one
considers the quantities of radioactive wastes
produced per year, those expected to be pro-
duced per year in the future, and the recorded
accidental release of radioactivity in event of
failure of an atomic power system. The recently
recorded uranium fire in the British power
reactor at Windscale, in which radioactive pro-
ducts (Iodinel31 was the major offender) were
released over a populated area, is an example
of the type of accident that has caused attention
to be focused on the problems of safe operation
of such reactors and civil liability in event of
accident.

Industrial and research programs employing
radiations do not deliberately employ man as the
test object, but rather attempt to plan operations
to avoid irradiations of man. On the other hand,
medical use of ionizing radiations involves direct
and planned use of ionizing radiations on man.
Control of the radiation hazard is, therefore, a
medical necessity, since this use of radiation has
made and is making a vital contribution to man’s
health and longevity but retains equally well the
possibility of detrimental effects on his health
and longevity, as well as its potential effects on
future generations.

BIOLOGIC EFFECTS

Effects of ionizing radiation may be manifested
in many ways, depending on the biologic sys-
tems involved and the factors governing the ex-
posure. Within months after Rontgen’s momen-
tous discovery of roentgen rays in 1895, pioneers
in roentgenology, such as Dodd, developed se-
vere dermatitis and submitted to first attempts
at skin grafting for control of the skin lesions.1
Daniel reported in 1896 a case of epilation fol-
lowing an attempt to demonstrate a metallic for-
eign body in the skull.2 One of Edison’s assist-
ants, Clarence Dally, became the first known vic-
tim of x-rays, dying from “x-ray cancer.”3 Radia-

Itions from radioactive materials were shown to
produce many of the same effects. The death of
Madam Curie, Nobel prize winner in nuclear
chemistry, has been attributed to the effects of

radiation. Development of cancerous lesions on
the fingers resulting from holding dental film in
the patient’s mouth during exposure has been
too common an occurrence among dentists, par-
ticularly those who entered dental practice be-
tween the years 1919 and 1927.

The increased incidence of leukemia among
radiologists is well documented.4"’' Other reports
indicate a higher incidence of abnormalities in
children of radiologists than in offspring of other
physicians.6 Radiation exposure is considered the
insidious common denominator in these and
other such studies.7 8

The biologic changes ascribed to radiation ex-
posure are initiated by the absorption of radiant
energy. This radiation may interact with atoms
of a biologic system to produce ionization, lead-
ing to disruption of molecular bonds and forma-
tion of highly oxidative radicals. Since the main-
tenance and growth of biologic structures are
dependent upon a multitude of chemical reac-
tions, which must be maintained in delicate bal-
ance, the absorption of radiant energy leads to
a change in this balance with ultimate modifica-
tion or destruction of the system. The ultimate
effect has been shown to depend on the dose of
radiation delivered, the time involved in its de-
liverv, and the type and energy of the radiation.
The spatial distribution of the ionization is also
a factor.

Since Muller’s experiments with Drosophila
thirty years ago, it has been known that ionizing
radiations increase the gene mutation rate. The
genes of mice have been shown to be 15 times
more sensitive to radiation induced mutations
than are those in Drosophila. Evidence of gene
mutations in human beings obtained in Japan
after the atomic blasts in Hiroshima and Naga-
saki indicates that radiation-induced mutation
rates in human beings appear to be close to those
observed in mice. Mutations in the germ cells
of the gonads are considered the most important
factor in determining the effect of radiation be-
cause of the involvement of future generations.
Furthermore, all mutations appear to be dele-
terious as has been observed in experiments with
fruit flies, various experimental animals, and in
cases of accidental exposure to man. On the basis
of fruit flv data, the most frequent mutations are
expected to cause minor impairments of body
function rather than gross changes. These ef-
fects include increased susceptibility to disease,
shorter life expectancy, and reduced fertility.

There is evidence that partial recovery from
the effects of radiation is possible. However, in
the case of genetic damage, most investigators
agree that these effects are cumulative. Genetic

APRIL 1958

115

damage is an example of a nonthreshold re-
sponse for which there is no recovery, and any
dose is damaging. Threshold effects require some
definite dose before observable changes occur
and generally some recovery from damage is
shown (figure 1).

DOSE OF IONIZING RADIATION

Fig. 1. Threshold versus nonthreshold phenomena.

UNITS FOR MEASUREMENT OF RADIATION

Radiation quantity can best be expressed in
terms of absorbed dose in ergs per gram of tis-
sue. Because of the difficulty in measuring en-
ergy absorption directly, several units have been
introduced. The roentgen (r) is the unit of
radiation exposure that was accepted in 1938,
indicating the amount of x- or gamma radiation
required to produce a definite quantity of ion-
ization in air under a particular set of conditions.
As ordinarily defined, 1 r of x-rays produces 87
ergs per gram of air or 93 ergs per gram of
water equivalent tissue. With the advent of the
medical use of radioactive isotopes, another unit,
the roentgen-equivalent-physical (rep), was de-
fined to include ionization resulting from alpha,
beta, and other radiations. This unit matched
the roentgen in terms of energy absorption in
tissue but lacked some of the limitations imposed
by definition on the roentgen. The rep has now
been replaced by the rad, which is defined as
the absorbed dose of radiation equal to 100 ergs
per gram of tissue.

The energy absorption in terms of ergs per
gram varies with the source and energy of the
radiation as well as the nature of the tissue. At
photon energies of 1 million volts (1 Mev)— the
average x-ray energy from a 2 to 3 million volt
x-ray machine or the energy from a cobalt tele-
therapv unit— the energy absorbed in ergs per

gram per roentgen of exposure is approximately
92 for muscle, 86 for fat, and 85 for bone. At
photon energies of 50,000 volts (50 Kev)— the
average x-ray energy from a 100 kilovolt x-ray
machine— these figures become 90 for muscle, 58
for fat, and 4(X) for bone. Other values may re-
sult from the use of equivalent roentgens of
other types of radiation, such as alpha, beta, neu-
tron, and so forth. Energy absorption in the vari-
ous tissues is thus expressed adequately in terms
of rads, whereas the roentgen is not a suitable
unit for this purpose.

Because the biologic effect on a particular ani-
mal, organ, or system may not depend directly
on the energy expended in the tissue for the
different types of radiation, another term, the
rad-equivalent-man or mammal (rem), has been
defined. The rem is the product of the dose in
rads and a term known as relative biologic ef-
fectiveness (RBE). The RBE must be measured
directly in terms of the effect of one type of ra-
diation on a particular system compared to the
effect of x-rays of known energy or, as is now
preferred, to the effect of the gamma rays of
either radium226 or cobalt60. Thus, the RBE is
a biologic unit, which may have different values
for the various organs of the same animal. Like-
wise, the rem is a biologic unit. Fortunatelv, the
RBE is 1.0 or very close to 1.0 for the x-rays and
gamma rays which are of the greatest impor-
tance in clinical medicine.

PERMISSIBLE LIMITS OF RADIATION
DOSE TO MAN

It is difficult to assay the harmful effects of
small doses of radiation. A base line can be es-
tablished using measured values of background
radiation. The average exposure is considered to
be of tbe order of 3 millirems per week or 5
reins per generation (from conception to age
30). This background radiation increases with
altitude and may be higher in some locations,
such as parts of Sweden, where radioactive ele-
ments in building materials result in values as
high as 8 millirems per week.9

Genetic evidence indicates there is no safe
dose of radiation.10 Thus, it becomes necessary
to balance the genetic risk against the benefits
derived from the various uses of radiation. A
National Academy of Science report estimates
that 30 to 80 r constitutes a “doubling dose,"
that is, this dose will double the spontaneous
mutation rate.11 On this basis, this report in-
cludes a recommendation that the maximum per-
missible dose (MPD) be set at 10 r to the go-
nads during the prereproductive lifetime of the
population. If 50 r is then accepted as the av-

116

THE JOURNAL-LANCET

erage doubling dose, a population receiving an
average of 10 r will show a 20 per cent increase
in gene mutation rate. This represents an ex-
pected increase in abnormalities in offspring at-
tributable to genetic mutation from the normal
incidence of 2 to 2.4 per cent.12 Although these
estimates are based on data derived from ex-
periments with fruit flies and mice, evidence
indicates that the data may also be valid for
human beings.

The National Committee on Radiation Protec-
tion (NCRP) has recommended that the MPD
of 0.3 rems per week, which was accepted prior
to February 1957, be reduced.13 This committee
recommended that the MPD be set at no more
than 0.3 rems in any one week, with a limit set
at 3.0 rems in any thirteen-week period and a
further limit set at 5 rems per year. For the pop-
ulation at large, a lower limit was recommended
of 0.5 rems per year, which is a factor of 10
below the “occupational exposure” levels. This
latter recommendation has been published in
terms of a gonadal dose to the whole population
now to exceed 14,000,000 rems per 1,000,000 peo-
ple from conception to pubertv, which would
average approximately 0.5 rems per year.

CONTROL OF RADIATION

Radioactive fallout. Background radiation for
all individuals in a given area may increase as
a result of weapon testing, atomic power plant
failure, or faulty waste disposal programs. This
will lead to increased quantities of external ra-
diation and to an increased probability of in-
gestion of radioactive materials. This situation
has now been shown to exist in a large part of
the United States and, particularly, the upper
Midwest as a result of radioactive fallout from
nuclear weapon testing.

The Minnesota Department of Health has just
released data on tests of Minnesota’s surface wa-
ters, which indicated that during the entire sum-
mer and early fall of 1957, levels of radioactivity
in Minnesota’s rainfall and in the surface waters
exceeded the maximum permissible concentra-
tion ( MPC ) of mixed fission products as estab-
lished in the National bureau of Standards
(NRS) Handbook 52 (values of MPC as given
must be altered in accordance with present
MPD).14 The data released do not constitute
evidence that a real hazard exists but only that
utilization of atomic energy in weapon testing
does result in a real and measurable increase in
background radiation. Knowledge of the in-
crease in radioactivity to the levels shown con-
stitutes a mandate that studies be initiated and
maintained to evaluate the hazard in terms of

concentrations of particular radioisotopes. The
studies must indicate whether or not removal of
these isotopes from drinking water is necessary
and must warn of any future increases in levels
of radioactivity.

Radioisotopes. Radium and thorium and their
products have been the radioactive materials
most commonly used in medicine. In the past,
radium has very often been stored in the office
safe in the hospital or office. This practice is a
violation of all rules of radiation safety.

Radioactive isotopes are now being used in
medicine for such purposes as diagnosis and
treatment of thyroid disease (1131), measure-
ment of blood (plasma) volume (1131 labeled
human serum albumin), measurement of red
cell volume and survival (Cr51), pernicious ane-
mia (Co60 labeled vitamin B12), tumor detec-
tion and treatment of blood dyscrasias (P32),
cardiovascular studies (1131, Na24), and metab-
olism of elements (P32, Na24, Ca45), or of la-
beled organic materials (S35, C14).

The relative hazard of the radioisotopes de-
pends on the lifetime and site of deposition in
the body and on the energy and tvpe of radia-
tions (table 1). Certain isotopes, such as Sr90,
1131, and Fe59, are considered particularly dan-
gerous because they are readily metabolized,
concentrated in critical organs, and remain for
long lifetimes. Quantities of particular isotopes
(microcuries) permitted in the body, if present
MPD is not to be exceeded, are given in table 2.

Roentgen rai/s for diagnostic purposes. The
hazards associated with the use of x-rays for
diagnostic purposes may be considered in 3
major categories: (1) equipment, (2) protective
devices, and (3) safety habits. Tables 3, 4, and
5 summarize recommendations for the control
of hazards in fluoroscopy and radiography. This
information was derived primarily from the spe-
cifications of the NCRP listed in NBS Handbook
60 on “X-rav Protection.”

Fluoroscopv presents the greatest potential
radiation hazard among the various diagnostic
procedures in which x-rays are used because of
the time that may be involved. If the precau-

TABLE 1

FACTORS DETERMINING HAZARD FROM RADIOISOTOPES

1. Quantity of material used.

2. Bodv retention.

3. Radiosensitivity of tlie involved tissues.

4. Relationship of involved tissues and or-
gans to body function.

5. Effective half life of the isotope.

6. Energy and character of the emanations.

APRIL 1958

117

TABLE 2

MAXIMUM PERMISSIBLE CONCENTRATIONS OF SOME RADIOISOTOPES IN THE BODY

Element

Emission

Site of
localization

Effective half
life (days)

MPC°

( microcuries)

Ra-26 + K dtr.
product

alpha

bone

1.6 x 101 2 3 4 5

0.03

Li (natural)

alpha

bone, lung, kidneys

30-120

0.003

Aulns

beta, gamma

kidneys

2.69

3.3

1131

beta, gamma

thyroid

7

0.1

Sr™

beta

bone

2.7 x 10»

0.3

Co60

beta, gamma

liver

9

1.0

Fe59

beta, gamma

blood

27

330

Cu4r>

beta

bone

151

22

S35

beta

skin

18

33

pa 2

beta

bone

14

3.3

Na24

beta

total body

0.61

5

C’4

beta

total body

130

250

“MPC is Based on MPD of 0.1 reins per week.

TABLE 3

FACTORS FOR CONTROL OF RADIATION EXPOSURE
IN FLUOROSCOPY

Fluoroscope

1. Maximum of 0.1 r/lir. /meter leakage radiation.

2. Cone and adjustable diaphragm to limit
the beam.

3. 2/2 mm. aluminum filter permanently fixed.

4. Target-to-table distance at least 18 in.

5. “High-low” milliamperage change over switch.

6. Cumulative timing device.

7. 1.5 mm. lead equivalent material in fluorescent
screen.

8. 10 r/min. maximum dose at the table top.

9. mm. lead equivalent drape during
horizontal use.

Protective devices

1. 1.5 mm. lead equivalent in doors and
walls to 7 ft.

2. Leaded aprons and gloves worn by flnoroscopist.

3. Radiation monitoring with film badges or pocket
dosimeters.

4. Leaded drapes overlying patient’s gonads when
possible.

Safety habits

1. Trained personnel.

2. Maximum utilization of inverse square law.

3. Small field size and limited time of operation.

4. Adequate dark adaptation.

5. No holding of patients.

6. Fluoroscopist’s hands (with gloves) not placed in
direct beam.

TABLE 4

FACTORS FOR CONTROL OF RADIATION EXPOSURE
IN RADIOLOGY

Radiographic machine

1. Maximum of 0.1 r/hr. /meter leakage radiation.

2. Cones or diaphragms to limit field size.

3. 2/2 mm. aluminum filter in medical units.

4. IK mm. aluminum filter in dental units.

5. Exposure meter to limit time.

6. Remote control switch operated from protected area.
Protection devices

1. 1.5-3 mm. lead equivalent in doors and walls to 7 ft.

2. Radiation monitoring recommended.

3. Leaded drapes overlying patient’s gonads when
possible.

Safety habits

1. Trained personnel.

2. Maximum utilization of inverse square law.

3. No holding of patients.

4. Use of lead drapes if patient attendance is neces-
sary.

5. Limit number of exposures by careful technic.

TABLE 5

FACTORS FOR CONTROL OF RADIATION EXPOSURE
FROM PORTABLE UNITS

1. Radiation monitoring is recommended.

2. Trained personnel.

3. No holding of patients or film cassette.

4. Lise of leaded aprons and drapes for patient and
operators.

5. Rotation of operators among various x-ray diag-
nostic units.

118

THE JOURNAL-LANCET

tions listed in the tables are observed, the radia-
tion to which the fluoroscopist and assistants are
exposed can be controlled well below present
MPD levels even for heavy schedules of work.
The use of old machines that do not adhere to
the specifications as listed by the NCRP may
be a real source of difficulty. Adequate shield-
ing in the tube housing and cone, shutters that
operate properly, and sufficient filtration are all
verv important in eliminating nnnecessarv ra-
diation exposure. The importance of using lead
aprons, gloves, and proper protective barriers
cannot be overemphasized. A means for peri-
odic radiation monitoring is also recommended.
This can be done simply and effectively without
great expense by using dental film, special moni-
toring film, or pocket dosimeters.

Actually, good safety habits are the most im-
portant factors in controlling radiation exposure.
Protection by distance (inverse square law),
limitation of the field size, control of time, ade-
quate dark adaptation, and avoidance of the
primary beam are all practices readily available
to the careful fluoroscopist. Scattered radiation
through the Bucky slot and from the patient and
table top leads to significantly higher dose rates
at the position occupied by the fluoroscopist dur-
ing horizontal fluoroscopy than during vertical
fluoroscopy. Therefore, an additional leaded
drape is recommended for use in horizontal flu-
oroscopy (table 3). Effect of field size and filtra-
tion on radiation levels at various points of inter-
est during fluoroscopy are shown in figure 2.

Even as fluoroscopes present the major haz-
ard to the operator, so these units also consti-
tute the greatest potential danger to the patient.
A dose rate of 10 r per minute is permitted at
the table top of a fluoroscope (table 3), so that
long periods of exposure result in a sizable pa-
tient dose. In a radiation hazard survey of flu-
oroscopes with no filtration and with a short
focal spot to table top distance, we have meas-
ured dose rates in excess of 35 r per minute at
table top. Under these conditions, the patient
may very well receive a dose sufficient to pro-
duce a sharp erythema. Bell has referred to the
patient hazard during fluoroscopy in an article
appropriately entitled “X-ray Therapy in Flu-
oroscopy.”13 He reported that under extreme
conditions, as during gastrointestinal fluoroscopy
at 80 kvp, 3 ma, with no added filter, that a
patient may receive a skin dose of 400 r and
a dose of 47.5 r at a depth of 10 cm. in the
tissues. A summary of measurements of patient
exposure under varying conditions of fluorosco-
py is shown in table 6. These measurements
serve to emphasize the importance of filtration,

control of time, and the limiting of field size to
keep the integral dose as low as possible.

In conventional, carefully executed radiogra-
phy, the operator is in little danger of radiation
exposure. Special technics, such as urography,
angiocardiography, cerebral angiography, and
aortography, which require the presence of a
physician and assistants in the radiographic
room, produce a potential radiation problem
that can be controlled by use of leaded drapes
properly placed, in addition to maintaining the
greatest possible distance from the x-ray beam.
A number of reports illustrate the pronounced
decrease in exposure to x-ray personnel that may
be effected by simple safety considerations. For
example, Ritvo and associates11’ reported that
with the use of proper coning, filtration, and
position, it is possible to reduce the dose to the
physician’s hands in urethrography from 66 mr
to less than 13 mr per exposure. Our own meas-
urements indicate exposure to the physician’s
hands during cerebral angiography can be re-
duced to 2 mr per exposure. If the hands ap-
proach the beam or if a larger beam is used,
the exposure increases 15 to 30 times. In fe-
moral arteriography and lumbar aortography,
a lead apron used as a drape can reduce the
exposure from 300 mr to less than 20 mr.

Photofluorographv deserves special mention
because of its use in extensive surveys for tuber-
culosis and certain hospital admission proce-
dures. Many of the older units were notoriously
hazardous for the operators. The majority of the
newer units have incorporated protective bar-
riers and remotely located switches for control-
ling exposure. Studies of this hazard have been
published by several authors.1718

Because of the confined areas in which these
units are operated, great care must be exercised
in placing the x-ray personnel in positions of
utmost safety. Small changes in location can
result in large differences in exposure. For this
reason, it has been recommended that a protec-
tion survey be made for all of these units.17 Fur-
thermore, it is recommended that personnel be
rotated among the various tasks assigned in this
survey program in order to keep the exposures
to any one group below the MPD.

Patient exposure from radiographic installa-
tions may reach hazardous levels if the filtration
of the machine is inadequate, if the primary
beam is not restricted by coning, and if the num-
ber of radiographs is not carefully controlled.
Average exposures for conventional radiographic
technics using x-rays filtered by 2 mm. of alu-
minum and with field size limited by cones or
diaphragms are summarized in table 7. These

APRIL 1958

119

Fig. 2. Effects of field size and filtration on radiation exposure in fluoroscopy

Fluoroscope 90 KV, 3 MA

Filtration , 1 mm. Al. n / 3 mm. Al.

’Id size

7x9

4x4 (in.)

7x9

4 x 4 ( in.)

A

12 r/min.

12 r/min.

7.2 r/min.

7.2 r/min.

B

.38 r/min.

.36 r/min.

C

4.2 mr./hr.

4.2 mr./hr.

4.0 mr./hr.

4.0 mr./hr.

D

550 mr./hr.

180 mr./hr.

400 mr./hr.

90 mr./hr.

E

240 mr./hr.

50 mr./hr.

200 mr./hr.

45 mr./hr.

F

450 mr./hr.

1 10 mr./hr.

200 mr./hr.

G

20 mr./hr.

15 mr./hr.

15 mr./hr.

12 mr./hr.

H

40 mr./hr.

19 mr./hr.

30 mr./hr.

17 mr./hr.

1

6 mr./hr.

6 mr./hr.

6 mr./hr.

6 mr./hr.

doses represent an average of our measurements
together with those reported by others.19-22

It may be seen that the skin dose to a pa-
tient’s chest is considerably higher in photoflu-
orography than in conventional 14 x 17 in. radio-
graphs of the chest. The average dose was found
to be about 750 mr, whereas, with the 14 x 17 in.
plate, the average dose was found to be 30 mr.
This represents about a 25-fold difference in
exposure. A corresponding difference in the
gonadal dose would be anticipated and has been

confirmed in the measurements reported by
Webster and Merrill.19

For exposures in which the gonadal dose
varies appreciably with sex, both values are
given. It is noteworthy that the use of a leaded
apron to protect the gonads for x-ray procedures
not involving this region permits reduction of
the gonadal dose by a factor of about 4. 2:1

Another diagnostic procedure involving un-
usual hazards to the operator is dental radiogra-
phy, in which exposures to the dentist may be

TABLE 6

PATIENT EXPOSURE IN FLUOROSCOPY

Exposure ( table top )
Skin close (5 min.)

Integral dose (5 min.)
10 x 10 cm. field

20 x 20 cm. field

Machine

No. 1 90 kv, 4 ma, i

No. 2 90 kv, 3 ma,

No. 3 image amplil
No. I
36 r/min.

180 r

52,000 gm.-r
(560 ergs)

208,000 gm.-r
(2,240 ergs)

i filter, fsd 15 in.

IK mm. Al., fsd 18 in.
with machine No. 2
No. 2
6 r/min.
30 r

17,300 gm.-r
( 186 ergs)

69,000 gm.-r
(743 ergs)

No. 3
1.5 r/min.
7.5 r

4,320 gm.-r
(47 ergs)

17,250 gm.-r
( 1 85 ergs )

120 THE JOURNAL-LANCET

TABLE 7

PATIENT EXPOSURE IN RADIOGRAPHY

AVERAGE EXPOSURE ( MILLIROENTGENS ) FOR CONVENTIONAL TECHNICS USING X-RAYS FILTERED HY 2 MM. AL.
AND WITH FIELD SIZE LIMITED BY CONES AND DIAPHRAGMS

Skin dose

Gonadal dose

Anatomy

View

(mr.)

(mr.)

Skull

AP

600

.02

Shoulder

AP

200

.02

Hand

120

.03

Chest

PA

30

.03

Chest ( P.R. ) *

PA

750

.75

Abdomen

AP

550

20 (150)**

G.l. series

PA

900

5 (50)

Lateral

2,000

10 (60)

Barium enema

PA

1,000

30 (200)

Lateral

2,500

40 (270)

Spine (lumbar)

AP

800

15 (150)

Lateral

2,300

40 (240)

Pelvis

AP

600

450 (150)

Lateral

2,000

1,500 (400)

Knee

AP

40

0,3

Foot

AP

20

0.2

0 PhotoHuorogram
00 Indicates gonadal dose t<

females

when significantly different

from males.

TABLE 8

PATIENT EXPOSURE

FROM DENTAL X-RAY UNITS

Doses to the skin:

65 kvp, 10 ma, .3 seconds

With added filter

Machine

No filter

With added filter

and fast film

No. 1

1.0 r

( M mm. Al. ) 0.66 r

0.22 r

No. 2

2.8 r

(2 )i mm. Al.) 0.7 r

0.24 r

No. 3

2.4 r

( 1 mm. Al. ) 1 .4 r

0.5 r

No. 4

2.4 r

(1 mm. Al.) 1.3 r

0.33 r

No. 5

4.0 r

(2 'A mm. Al.) 2.2 r

0.7 r

All machines properly coned.

Approximately ffd 14 in.

Maximum estimated dose to si

in for 14 exposures (full mouth

series)

With added filter

Machine

No filter

With added filter

and fast film

No. 1

9 r

6 r

2 r

No. 2

26 r

6.5 r

2.2 r

No. 3

22 r

13 r

4.7 r

No. 4

22 r

12 r

3.1 r

No. 5

37 r

20 r

6,5 r

Gonadal dose estimated per full mouth series
4-5 mr. 2 mr.

less than 1 mr.

Information obtained through courtesy of Dr. E. E. Peterson, University of Minnesota School of Dentistry.

as high as 1.5 r per hour of operation.24 The
practice of holding the film in the patient’s
mouth must be prohibited for reasons already
mentioned. The operator of a dental x-ray ma-
chine may receive a total body dose of 125 mr
per full mouth set of x-rays if care is not exer-
cised.

Exposures to patients from 5 dental units at

the University of Minnesota Dental Clinic are
summarized in table 8. These units were oper-
ated as installed and then with addition of
proper (maximum useable) filter and with the
usual medium speed and then with the fastest
film available. Proper coning of the beam was
utilized in all procedures. This table illustrates
the reduction which is readily possible in radia-

APRIL 1958

121

tion dose to the patient in dental radiography.

Ionizing radiations used in such devices as
shoe-fitting Huoroscopes are also directed de-
liberately at man. These units are x-ray ma-
chines, usually operated at 50 kvp, 3-8 ma, 7.5-
20 cm. focal-skin distance and with or without
the proper 1 mm. aluminum filter. These units
may or may not be adequately surrounded with
lead barriers for operator protection. The Min-
nesota State Department of Health surveyed 138
of these machines and found that the radiation
dose to the foot ranged from 0.4 to 23 r per ex-
posure with an average of 1.96 r. Radiation to
the operator ranged from 0 to 250 mr per hour
with an average of 10.5 mr per hour. In the
past, control of these machines has been under-
stood to mean adequate protection for the op-
erator, limited time of exposure (5 seconds),
dose to the foot per exposure not to exceed 1 r
and an annual limitation of 15 exposures per
foot (a very difficult number to control).25 At
the present time, the use of these machines is
prohibited in the Commonwealth of Pennsylva-
nia, in New York City, and in Minneapolis (by
ordinance). The American Medical Association
at its meeting in Philadelphia in December 1957
took a very strong stand to eliminate further use
of Huoroscopes for the fitting of shoes. At the
present time, any recommendation favoring con-
trol of these units rather than their elimination
would not appear to be in order.

Radiation therapy also carries a somatic and
genetic risk for the patient. When treating ma-
lignant disease, there can be no question that
the risk is justified. However, the use of x-rays
and radium in treating benign conditions, par-
ticularly those of the skin, such as acne, neuro-
dermatitis, hemangioma, and verucca of the
hands and feet, must be carefully limited to
conditions which cannot be effectively controlled
by other methods.

Radioactive isotopes for most clinical pur-
poses carry practically no radiation risk, except
in the presence of pregnancy. We feel that it is
desirable to withhold even small tracer doses of
radioisotopes in pregnancy because of potential
hazard to the fetus. There is some debate con-
cerning the relative radiation hazard when using
radioactive iodine to treat hyperthyroidism in
patients under 35 years of age. The hazard of
inducing thyroid malignancy is as yet theoretic
and must be balanced in the physician’s evalua-
tion against the known small but, nevertheless,
real hazards of other therapeutic methods. It
is unlikely that other properly conceived human
uses of radioisotopes will represent any real
hazard to patients.

KADIATION DIARY

How might one determine his exposure to radia-
tion over a period of months and years? For
individuals whose occupations require the use
of ionizing radiations, this problem is most ef-
ficiently handled by the use of film monitoring
badges or pocket dosimeters carried at various
parts of the body. The exposures received can
be logged for a continuous record. Many hospi-
tals are doing this routinely to safeguard the
health of their workers, as well as to provide
legal protection for the hospitals.

For the population in general, this task is
much more difficult, if not impossible, to carry
out satisfactorily. The NRCP has given thought
to this problem in order to assist the state health
departments in setting up specifications for the
control of radiation hazards.26 A radiation diary
to be carried by everyone from the cradle to the
grave has been considered. However, the prob-
lems in administering such a program are over-
whelming to say nothing of the added instru-
mentation and training required to make logical
estimates of gonadal doses for all exposures. For
example, there are some 100,000 diagnostic x-ray
units in operation in the United States with only
aborft 5,000 certified radiologists. Even among
this group of specialists, there would be consid-
erable difficulty in estimating gonadal doses or
even skin doses for all exposures.

SUMMARY

Ionizing radiations have in the past served a
verv important role in the medical advances re-
sponsible for the improved health and longevity
of our population. They have served equally well
in industry by contributing to our improved
living standards. All of us should be aware that
ionizing radiations may equally well constitute
health hazards. Unwiselv used, some increased
longevity and well-being may be sacrificed.

The medical profession has a moral responsi-
bility to keep the radiation dose at a minimum
compatible with good medical diagnosis and
therapy. Radiation dose should be known and
controlled for the patient, physician, assistants,
and general public. The use of ionizing radia-
tions for diagnostic purposes should not be a
substitution for careful physical examinations
and complete patient histories. The benefits of
ionizing radiations for therapeutic purposes
should be carefully weighed against the risks.
During the childhearing period, the utilization of
x-rays or administration of radioisotopes should
be more carefully controlled than in older pa-
tients. It may be desirable to completely elim-
inate the use of radioisotopes and to sharply

122

THE JOURNAL-LANCET

curtail the use of x-rays during pregnancy. Ra-
diographic rather than fluoroscopic examination
may be the diagnostic choice in studies of in-
fants and in most studies of the heart and lungs,
since one minute of fluoroscopic examination
results in a radiation dosage comparable to that
received from several hundred radiographs.

The medical profession must constantly strive
to improve its x-ray equipment so that required
studies can be performed with a minimum of
radiation. This implies at the present time the
use of adequate radiation barriers around the
x-ray tubes; adequate cones or diaphragms to
limit the size of the radiation fields; high speed
intensifying and fluoroscopic screens and film;
adequate filtration on all units, including porta-
ble x-ray machines; adequately protected con-
trol areas for the diagnostic and therapy ma-
chines; and use of suitable lead drapes, aprons,
gloves, and other protective devices.

Training in the use of ionizing radiations can-
not be overemphasized. Poor safety habits on

REFERENCES

1. Macy, I. A., Jr.: Walter James Dodd. Boston: Houghton

Mifflin Co., 1918.

2. Daniel, J.: The Depilatory action of the x-rays. New York

Med. Rec. 49:595, 1896.

3. Evans, W. A.: Science of Radiology, edited by O. Glasser.
Springfield, Illinois: Charles C Thomas, 1933.

4. Warren, S.: Longevity and causes of death from irradia-

tion of physicians. J.A.M.A. 162:464, 1956.

5. March, H. C.: Leukemia in radiologists in a 20-year period.
Am. J. M. Sc. 220:282, 1950.

6. Macht, S. H., and Lawrence, P. S.: National survey of

congenital malformations resulting from exposure to roent-
gen radiation. Am. J. Roentgenol. 73:442, 1955.

7. Murphy, D P.: Ovarian irradiation and health of the sub-

sequent child. Review of more than 200 unreported preg-
nancies in women subsequent to pelvic irradiation. Surg.,
Gynec. & Obst. 48:766, 1929.

8. Giles, A. M.: Pregnancy following pelvic irradiation. J.

Obst. & Gynaec. Brit. Emp. 56:1041, 1949.

9. Sievert, R. M., and Hultqvist, B.: Variations in natural

gamma radiation in Sweden. Acta radiol. 37:388, 1952.

10. Glass, B.: Genetic basis for limitation of radiation exposure.
Am. J. Roentgenol. 78:955, 1957.

11. Biological effects of atomic radiation. Washington, D. C.:
National Academy of Sciences. Nat. Res. Council, 1956.

12. Crow, J. F.: Genetic considerations in establishing maximum
radiation doses. Radiology 69:18, 1957.

13. Maximum permissible radiation exposures to man. National
Committee on Radiation Protection and Measurement. Radi-
ology 68:260, 1957.

14. Interim report on biological effects of radiation. Minnesota
Governor’s Committee on Atomic Development Problems.
February, 1958.

the part of the technician or the physician may
destroy all the benefits of the protective bar-
riers and devices in an x-ray department. The
presence of a technician or physician may be
required and desirable during an x-ray exposure,
but lack of protective aprons and gloves can
only be considered a very poor safety practice.

Cognizance of radiation hazards coupled with
good judgment and common sense27 will go a
long way in reducing the exposure of our whole
population to ionizing radiations for diagnostic
purposes. It is not unreasonable to expect that
with improvement in technic, radiation to the
general population from medical x-rays present-
ly estimated at approximately 5 r per thirty
years ( equal to the natural background ) may
be substantially reduced despite an increased
use of ionizing radiations in medicine. On this
basis, we believe that no significant genetic prob-
lems need be anticipated in future generations
as a result of the use of ionizing radiations in
medicine.

15. Bell, A. L. L.: X-ray therapy in fluoroscopy. Radiology

40:139, 1943.

16. Ritvo, M., D’Angio, G. J., and Rhodes, I. E.: Radiation haz-
ards to nonradiologists participating in x-rav examinations.
J.A.M.A. 160:4, 1956.

17. Van Allen, W. W.: Secondary radiation fields surrounding

photofluorographic equipment. Radiology 56:832, 1951.

18. Birnkrant, M. I., and Henshaw, P. S.: Further problems

in x-ray protection; radiation hazards in photofluorography.
Radiology 44:565, 1945.

19. Webster, E. W., and Merrill, O. E.: Radiation hazards.

II. Measurements of gonadal dose in radiographic examina-
tions. New England J. Med. 257:811, 1957.

20. Sorrentino, J., and Yalow, R.: Nomagram for dose deter-

minations in diagnostic roentgenology. Radiology 55:748,
1950.

21. Billings, M. S., Norman A., and Greenfield, M. A.:
Gonad dose during routine roentgenography. Radiology 69:
37, 1957.

22. Baily, N. A.: Patient exposure to ionizing radiation in dental
radiography. Radiology 69:42, 1957.

23. Laughlin, J. S., Meurk, M. L., Pullman, I., and Sherman,

R. S.: Bone, skin, and gonadal doses in routine diagnostic

procedures. Am. J. Roentgenol. 78:961, 1957.

24. Nolan, W. E., and Patterson, H. W.: Radiation hazards

from use of dental x-ray units. Radiology 61:625, 1953.

25. Safety code for the industrial use of x-rays. Am. Standards
Assoc., New York, 1946.

26. Regulation of radiation exposure by legislative means. Nat.
Bureau of Standards, Handbook 61, Washington, December,
1955.

27. Stone, R. S.: Common sense in radiation protection applied

to clinical practice. Am. J. Roentgenol. 78:993, 1957.

APRIL 1958

123

Injury from Blunt Trauma to the Chest:

Its Management in the Community Hospital

FRANK E. JOHNSON, M.D.

M inneapolis, Minnesota

A fall caused by tripping or slipping contin-
xY ues to supply each doctor’s practice with a
constant number of patients with chest injuries.
The great majority of such injuries are of a rela-
tively minor nature, such as abrasion or con-
tusion to the chest wall or simple rib or costal
cartilage fracture. The over-all incidence of chest
injuries, however, is increasing directly as the
modern automobile becomes faster, the modern
highway becomes smoother and straighter, and
activities of life become more mechanized. Tho-
racic injuries resulting from automobile accidents,
as from other sources of major trauma, commonly
represent only a part of the total body injury,
which may include a variety of fractures to the
extremities, injury to the abdominal viscera, and
serious head injury. By the nature of the organs
affected, however, thoracic trauma is often of
major importance in the total body injury and
demands prompt, effective treatment if life is to
be salvaged. The fact that the majority of these
serious chest injuries occur at places remote from
the large medical centers with their specialized
equipment and personnel prompts the writing
of this article. It is felt that earlv application of
certain simple technics, using equipment avail-
able in even the smallest hospital, will result in
salvaging the lives of a number of patients with
chest injuries who might otherwise be lost at
the local hospital or in transit to the medical
center.

Case 1. A 49-year-old white man suffered a severe
bilateral crushing injury of the chest when he was
caught under his tractor after it overturned. He was
admitted to a community hospital in western Minnesota
where he was treated with tracheotomy, bilateral inter-
costal catheter drainage of the pleural space, and blood
transfusions. Severe subcutaneous emphysema is to be
noted in figure la. It should be recognized as one sign of
an undrained pneumothorax. In itself this not harmful.
It is, rather, evidence of beneficial decompression of a
pneumothorax into the soft tissues. In figure lb, the final
radiologic result is evident. The patient continues to
work full time as a farmer.

frank e. johnson is clinical instructor in surgery at
the University of Minnesota.

MINOR CHEST INJURIES

Abrasion, contusion, and laceration. Of the lesser
injuries, lacerations (after suture), abrasions,
and burns of the chest, as elsewhere on the body,
are best treated by the “open method” without
dressings, antiseptics, or ointments but with a
twice daily soap and water washing.

Simple fracture of rib or costal cartilage. For
the patient who complains of chest pain aggra-
vated by straining, bodily movement, deep
breathing, or coughing and who gives a history
of recent injury, a properly conducted physical
examination is the most reliable means of diag-
nosing a fracture of a rib or costal cartilage. Each
rib should be examined by exerting pressure on
it away from the area of injury and pain. The
motion caused at the fracture site by this ma-
neuver aggravates the patient’s pain and avoids
the confusing factor of soft tissue tenderness
when pressure is applied at the site of trauma.
The lower six ribs are counted and examined,
starting with the twelfth and proceeding cephal-
ad posteriorly. Because of the presence of the
scapula and heavy shoulder muscles posteriorly,
the upper ribs are best counted off and examined
anteriorly or in the axilla. Whereas, physical ex-
amination is most reliable in the diagnosis of a
chest-wall injury, the roentgenogram is essential
in the discovery of an intrathoracic injury. We,
therefore, omit roentgenograms for rib detail and
order instead routine upright posteroanterior and
lateral x-ray films of the chest for signs of intra-
thoracic disorder. In patients with simple rib
fracture, the routine chest x-ray film may be nor-
mal and, in such cases, the physician’s function is
to provide relief of pain and discomfort. In most
instances, the nonelastic canvas rib belt snugly
applied provides sufficient immobilization of the
fracture and consequent relief of pain, so that
respiration is freer, cough is effective, rest is
possible, and the patient is able to resume even
rather heavy labor in a relatively short time. In
patients with pulmonary emphysema or marginal
respiratory reserve of any cause, the splinting of

124

THE JOURNAL-LANCET

Fig. 1 a (left). Note
severe subcutane-
ous emphysema, b
(right). Final ra-
diologic result.

Fig. 2 a (left). Admission roentgenogram showing multiple rib fractures, fracture of the left clavicle, and left pneu-
mothorax with severe shift of mediastinal structures to the right, b (center). Improved appearance of chest two
days after injury, c (right). Chest roentgenogram twenty-seven days after injury.

Fig. 3a (left). Im-
mediate preopera-
tive film, b (right).
Immediate postde-
cortication film.

APRIL 1958

125

respiration with simple rib fracture may be a
serious handicap and lead to the accumulation of
pulmonary secretions and consequent atelectasis
and pneumonitis. In these patients, application
of certain measures, which will be discussed
under the heading of major thoracic trauma, may
be necessary.

MAJOR THORACIC TRAUMA

Injury to the chest of a more serious nature is
best considered from the viewpoints of: (a) the
effect on the organs and structures under the
protection of the rib cage and (b) the effect on
the mechanics of respiration. In considering the
organs and structures which may suffer damage
in any thoracic injury, we at once recall the
heart, lungs, great vessels, esophagus, trachea,
bronchi, thoracic duct, and diaphragm. There
are, of course, several additional important struc-
tures which depend upon the protection of the
rib cage albeit they lie below the diaphragm.
These are primarily the spleen, liver, pancreas,
and kidneys. Some of the hollow viscera, such
as the stomach, duodenum, and portions of the
colon, are at least partially intrathoracic.

The organ most often presenting clinical evi-
dence of damage in major chest trauma is the
lung. Simple contusion of the lung with a
localized area of parenchymal hemorrhage casts
a shadow upon the x-ray film but usually re-
quires no specific treatment. More often there is
a laceration of the parenchyma with air leak and
bleeding, which cause a hvdropneumothorax on
the upright chest film. While the air leak may
not be rapid, it always has the potential of caus-
ing serious disturbance, such as a tension pneu-
mothorax. The bleeding most frequently is from
the low pressure pulmonary system and tends to
cease spontaneously before any great amount
is lost. Treatment consisting of controlled suc-
tion through an intercostal catheter brings
prompt expansion of the lung and evacuation of
the blood. Early active treatment is important
to avoid the problems presented by tension pneu-
mothorax (figure 2) or clotted hemothorax (fig-
ure 3) and trapping of the lung in a collapsed
state.

Case 2. J. T., a 46-year-old white man was crushed
between the bumper of an automobile and a wall. He
was severely dyspneic and cyanotic on arrival at the
hospital. The admission x-ray film showed multiple
rib fractures, fracture of the left clavicle, and left pneu-
mothorax with severe shift of the mediastinal structures
to the right (figure 2a.) Treatment was begun within
an hour after the injury and consisted of ( 1 ) suction
applied to a catheter inserted in the third interspace in
the midclavicular line, (2) Novocain block of the 12
intercostal nerves on the left, ( 3 ) nasotracheal catheter
suction on 4 occasions during the hospital stay. Im-

proved x-ray film appearance of the chest two days after
injury ( figure 2b ) was correlated with great improve-
ment clinically. Figure 2c shows the condition of the
chest twenty-seven days after injury at which time the
patient was clinically well and doing light work at home.

In this case, the simple measures mentioned
previously brought dramatic improvement and
led to the ultimate attainment of a good clinical
result.

Case 3. M. II. is a 22-year-old man in whom left hemo-
thorax developed as a residt of an injury in August 1952.
Blood was aspirated from the chest occasionally but
never completely. This blood clotted, became organized,
and was gradually converted to mature scar tissue. When
he was seen in March 1953, the severe contraction of
the left hemithorax and trapping of the lung were ob-
vious. Decortication was performed. The entire visceral
and parietal peel were removed. The lung expanded
well to fill the hemithorax. Figure 3a was taken just
prior to operation. Figure 3 h is an immediate postop-
erative film.

The fragile vascular spleen is frequently dam-
aged with chest trauma. Hemorrhage tends to
be continuous and serious when the capsule is
lacerated together with the pulp. If the capsule
remains intact but the pulp is lacerated, delayed
hemorrhage, particularly within the first three
weeks after the injury, is possible. The treatment
is splenectomy.

The liver is similarly liable to fracture and
hemorrhage. In addition, the escape of bile into
the peritoneal cavity may complicate the prob-
lem. In such cases, the treatment is debridement
of devitalized parenchyma, control of bleeding
points, and drainage of the area.

The kidney may suffer contusion or laceration
in a chest injury. Bleeding occurs, however, in
a comparatively closed space and has a greater
tendency, therefore, to be self-limited than is
true in the case of wounds of the liver or
spleen. Emergency treatment consists of suppor-
tive blood transfusion, and early operation is
onlv rarely necessary.

Traumatic pancreatitis is diagnosed by the
elevated serum or urine amylase and is, perhaps,
best treated by nonoperative means as with
acute pancreatitis of undetermined etiologv.

Damage to the heart is common and varies
from transient pericarditis to severe contusion
and even rupture of the myocardium. Damage is
detected and progress followed by serial electro-
cardiograms, as well as repeated physical ex-
aminations. Patients with evidence of myocardial
damage are treated with rest, as one woidd treat
a patient with coronary thrombosis. There would
seem to be, however, little place for the use of
anticoagulants in this circumstance. Cardiac
tamponade may occur early due to active bleed-
ing or two to three weeks later as a small amount

126

THE JOURNAL-LANCET

Fig. 4 a (left). Im-
mediate preopera-
tive portable an-
teroposterior film of
tire chest, b (right).
Portable anteropos-
terior chest film
immediately after
open pericardioto-
my. Catheter in
c o m m u n i c a t i o n
with pericardial
space but not in
contact with the
heart.

of blood in the pericardial sac by hemolysis in-
creases its osmotic pressure and causes a shift
of fluid into the sac in the manner that a sub-
dural hematoma increases its volume. One
should, therefore, be alert for the classic signs
of increased venous pressure, falling arterial
pressure, paradoxical pulse, and increased card-
iac silhouette on the x-ray film. The heart tones
are muffled in a typical case, but this is an un-
reliable sign in our experience. Paracentesis
should be performed for relief of symptoms and
may be lifesaving. Open pericardiotomy through
the bed of the left fifth costal cartilage with
evacuation of the liquid and clotted blood and
postoperative suction drainage is indicated if
tamponade recurs. This procedure appeals to us
as a simple, safe, and somewhat more certain
method of evacuating the pericardial space and
controlling bleeding points.

Case 4. M. D., a 46-year-old man, suffered a steering
wheel injury of the chest and a fracture dislocation of
the head of the right femur in an automobile accident.
He was severely dvspneic, cyanotic, hypotensive, and
mentally clouded when admitted to the Minneapolis

Fig. 5 a (left). Film taken
shortly after injury, b (right).
Film taken two years after
injury. Residual traumatic
aneurysm has been resected
and replaced with an ivalon
prosthesis. (Photograph pre-
sented witli permission of C.
R. Hitchcock, M.D., chief of
surgery, Minneapolis Gen-
eral Hospital).

General Hospital. Adequate ventilation was regained
by correcting left pneumothorax with intercostal cath-
eter drainage, and a tracheotomy was performed. Ap-
proximately two weeks after injury, the patient devel-
oped the classical signs of cardiac tamponade. Figure
4d is an immediate preoperative portable anteroposterior
film of the chest. Figure 4b was taken just after open
pericardiotomy and removal of 700 cc. of old blood.
The catheter has been sutured in place in communica-
tion with the pericardial space but not in contact with
the heart. There was no recurrence, and recovery was
complete.

Of the great vessels, the aorta is the one most
commonly injured. It tends to tear at a point
just distal to the left subclavian artery. The
common explanation for this is said to be that
the aorta is fixed in this area by the ligamentum
arteriosum and upper extremity vessels. It may
be that the narrow, tough, unyielding left vagus
and recurrent laryngeal nerves provide the ful-
crum over which the aorta is fractured. In the
past, we could offer, in addition to supportive
blood transfusion, little more than prayer. How-
ever, laboratory experience with the method
of bypass of the occluded descending thoracic

APRIL 1958

127

aorta pumping oxygenated blood from the left
atrium to the femoral artery recently gave us
courage to operate with near success upon one
case of acute rupture of an aneurysm of the de-
scending thoracic aorta. It seems only logical
that this method will be applied successfully to
traumatic rupture of the thoracic aorta.

Case 5. G.D., a 15-year-old boy, was in an auto-
mobile accident in which he sustained mild head and
kidney injuries and more severe trauma to the chest.
X-ray film evidence of a mass developed in the apex
of the left chest. Physical examination revealed a bruit
in this area, signs of coarctation of the aorta (hyperten-
sion in the arms and hypotension in the legs), and an
acute left ventricular strain pattern on the electrocardio-
gram. These signs gradually subsided over a period of
one month. Figure 5 a was taken shortly after the acci-
dent. Figure 5b was taken two years after injury. The
residual traumatic aneurysm was resected and replaced
with an ivalon prosthesis.

Fracture of the trachea causes an air leak to
the soft tissues, and, if the fracture site is separ-
ated sufficiently to enable the peritracheal soft
tissue to fall in, respiratory obstruction occurs.
Air leak to the mediastinum may cause compres-
sion of the low pressure vena cavae and pulmon-
ary vessels with consequent circulatory failure
due to poor filling of the heart. Immediate
tracheotomy and passage of the tube beyond the
area of tracheal tear may be lifesaving by re-
establishing the airway and decompressing the
mediastinum. Fracture of a major bronchus
causes a pneumothorax and an air leak which
cannot be overcome with intercostal catheters.
Nevertheless, the catheters prevent or relieve a
tension pneumothorax and are essential emer-
gency measures to maintain life until definitive
treatment can be undertaken. After the im-
mediate threat is removed, fracture of the
trachea or a major bronchus is best treated by
early operation and primary repair of the lacer-
ation. This solves the immediate problem of air
leak or respiratory obstruction and prevents the
later complication of tracheal or bronchial sten-
osis.

Aside from the problem of injury to the
various organs housed within the rib cage, we
are concerned with the disturbance in the physi-
ology of respiratory function caused by major
nonpenetrating injuries of the chest.

Normal respiratory function resolves itself into
two parts : ( 1 ) ventilation of the pulmonary
alveolus and (2) gas exchange at the alveolo-
capillary junction. While there may certainly
be disturbance in gas exchange due to parenchy-
mal edema and hemorrhage in areas of contusion
and laceration of the lung, the greatest distur-
bance in respiratory function residts from the
effect of trauma upon the mechanics of ventila-

tion. Therefore, for the puqx>se of this presen-
tation, disturbances at the alveolocapillary inter-
phase will be disregarded.

The normal movement of air in and out of the
lungs depends upon: (1) the integrity and mo-
bility of the thoracic cage and diaphragm, (2)
elasticity and distensibility of the lung, (3) an
intact pleura, and (4) a clear airway.

Each of the foregoing factors must be con-
sidered individually as we approach the prob-
lem of correcting disturbances in ventilation as-
sociated with chest injuries:

1. Integrity of a mobile thoracic cage and dia-
phragm involves: (a) sufficient rigidity of the
chest wall to prevent any paradoxical motion
under physiologic pressures, sufficient volume to
allow adequate exchange, and sufficient mobility
for expansion in all diameters; and (b) a good
mobile capacity of the diaphragm, for, in quiet
breathing, this muscle is said to account for 60
per cent of the total air ventilated.

Clinically, after injury with multiple rib frac-
tures, we often see loss of rigidity and paradoxi-
cal motion of the chest wall on respiration. This
paradoxical motion serves to increase the physio-
logic dead space by shuttling air back and forth
between that portion of the lung subadjacent to
the area of “flail chest” and the remainder of
the lung. Perhaps, of equal importance, paradoxi-
cal respiration acts as a handicap to effective
cough. The canvas rib belt or adhesive strapping
serves to minimize the paradoxical motion. Mea-
sures aimed at stabilizing the chest wall by use
of an external traction apparatus have long been
standard practice. However, it has been our
experience that, if we direct our efforts toward
correcting the other more easily controllable
alterations affecting ventilation, the use of an
external traction apparatus is rarely necessary.
Any advantage of external traction is probablv
outweighed by its disadvantages. One disad-
vantage is that the apparatus and dressing pre-
vent easy access to a portion of the chest for
physical examination and nursing care. Another
and more important disadvantage is that the at-
tachment of an apparatus of any kind to a
patient tends to discourage his being turned
frequentlv, and we lose, as a result, the aid of
gravity in clearing bronchial secretions.

Effective restriction of mobility of the chest
wall is imposed by the involuntary spasm of
muscles in response to pain. In the patient with
severe embarrassment of respiration, opiates are
to be avoided because of their depressant effect
upon the action of the bronchial cilia, the cough
reflex, and the respiratory center. Pain in this
situation is ideally and simply controlled bv

128

THE JOURNAL-LANCET

paravertebral intercostal nerve block depositing
5 to 10 cm. of 1 per cent procaine just inferior to
the angle of each affected rib plus one or two
ribs above and below those affected. It is a
relatively simple bedside procedure to block all
the intercostal nerves on one or both sides. The
relief of pain ends splinting, with the residt that
the depth of respiration is increased and cough
is no longer suppressed. This is a rewarding pro-
cedure in that the clinical improvement is often
dramatic, and even the most undemonstrative
patient cannot conceal his gratitude. In most in-
stances, the Novacain block brings relief which
far outlasts the anesthetic effect and frequently
only a single injection is required.

The diaphragm is the single most important
respiratory muscle. We must take every step to
remove handicaps to its freedom of action. The
aforementioned Novacain intercostal block con-
tributes a good deal by the relief from splinting
of the diaphragm due to pain. Abdominal dis-
tention due to adynamic ileus associated with
the chest injury or reflecting a concomitant ab-
dominal injury may seriously impair diaphrag-
matic motion. Since abdominal distention caused
by ileus is much easier to prevent than to correct
after it is established, the prompt early place-
ment of a nasogastric tube is important in pre-
serving mobility of the diaphragm and, in addi-
tion, is good first aid treatment of possible but
as yet undiagnosed intra-abdominal injury. The
gastric suction should be maintained until active
bowel sounds are present.

2. In normal ventilation, the lung must be
distensible so that the lung volume can increase,
and it must be elastic to permit passive recoil
during expiration. After an injury, the factors
of distensibility and elasticity of the lung are
disturbed in areas of contusion and hemorrhage
into the parenchyma. Such changes are not
easily or rapidly reversible. We will, therefore,
accept this alteration and extend our efforts in
other more profitable directions.

3. An intact pleura is essential for efficient
ventilation of the lung. In a pneumothorax, any
expansive force is partially lost on the elasticity
and distensibility of the air in the pleural space.

A pneumothorax is almost always present in
a serious chest injury and is readily seen on the
upright x-ray film of the chest. The importance
of taking the film in the upright position is
worthy of emphasis. On a flat film, considerable
fluid may be layered out posteriorlv and air
anteriorly with the lung suspended between
these two and with lung markings reaching the
chest wall laterally. Sizable pneumohemotho-
races have been overlooked on the flat film by

c

Fig. 6 a. Simple water seal drainage, (b). Simple water
seal drainage with trap bottle to collect secretions, (c).
Three bottle suction.

even the most experienced physician. If it is
felt unwise to secure an upright film because of
the patient’s precarious condition, the lateral
decubitus film will serve as an excellent second
choice in demonstrating the presence of a pleural
complication. In management, we will be guided
by the general rule that the pleural space must
always be kept empty, and one of the first acts
of treatment should be to place a catheter in
the pleural space and apply suction ( figure 6 ) .
The third interspace in the midclavicular line is
a convenient area to place the largest urethral
catheter that will pass through the available tro-
car. This catheter removes the air readily but is
not always successful in removing the blood.
In the latter circumstance, a second catheter
should be placed in the sixth or seventh inter-
space in the midscapular line.

This procedure is illustrated in figure 6. Simple
water seal drainage is shown in figure 6a. A
column of water equal to the negative intrapleur-
al pressure prevents aspiration through the
catheter to the chest cavitv. For this reason,
the water seal bottle must be well below the
level of the patient ( floor level is usual ) . As
positive intrapleural pressure on exhalation be-
comes sufficient to overcome the column of
water between the tip of the water seal tube and
the surface of the water, air and fluid in the
pleural space are discharged into the water seal
bottle. Since it is desirable to have as little resist-
ance as possible to egress from the pleural space,

APRIL 1958

129

the tube should be no more than 1 cm. below the
surface of the water in a gallon bottle.

Figure 6b illustrates simple water seal drain-
age with a trap bottle to collect secretions and,
thus, prevent change in the fluid level and con-
sequent change in the resistance to outflow
through the water seal.

Three-bottle suction is portrayed in figure 6c.
Trap bottle, water seal, and controlled negative
pressure suction bottle comprise the series. Suc-
tion is applied to the third bottle bv a Stedman-
tvpe pump or the common laboratory water
suction, which is available in all hospitals. The
tube, which is open to the atmosphere, is placed
14 cm. below the surface of the water. Thus, we
know that when the suction apparatus pulls air
from the atmosphere through this tube, we are
maintaining 14 cm. negative pressure throughout
the system. Fluid aspirated from the chest drops
into the trap bottle, and air leak is manifested
by bubbling through the water seal bottle. The
water seal bottle also prevents aspiration to the
pleural space if the suction pump should fail.

In addition to assisting ventilation by allowing
the greatest possible expansion of the lung,
catheter drainage indicates the amount of blood
lost in the chest cavity and also tells if and when
the bleeding or air leak ceases. With the know-
ledge that while the chest catheter is in place,
a tension pneumothorax will not develop and
blood will not silently accumulate in the chest
cavity, the physician is permitted a much less
troubled sleep.

4. The fourth factor in proper ventilation of
the lungs is a clear airway. The maintenance of
a clear airway is normally achieved by ciliary
action, the cough reflex, positional change and
postural drainage, bronchial peristalsis, and col-
lateral respiration. The cilia clear the airway bv
propelling a blanket of mucus along the tracheo-
bronchial tree. Foreign bodies are moved toward
the larynx on this blanket. Ciliary action is im-
paired by drying, by drugs which thicken or thin
the mucus, and bv anesthetics. Thus, we must
keep the patient’s atmosphere humid, avoid
drugs of the nature of atropine or potassium
iodide, which alter the character of the mucus,
and avoid opiates which depress the cilia.

Coughing is essential to the maintenance of
the airway and depends upon the integrity of
the cough reflex along with an ability to build
up an adequate volume and pressure behind
a closed glottis and then release it suddenly.
Relief of pain, stabilizing the chest wall, and
correcting pleural complications all contribute
to a more effective cough. Most important of
all, patients must be informed of the reason for

coughing and raising mucus and then be en-
couraged frequently by the nurse and physician
to do so. In those cases in which the patient
cannot bring himself to cough, suction applied
to a catheter passed through the nose and into
the trachea removes secretions and teaches the
patient that he can indeed cough (figure 7).

A catheter possessing a gentle curve passes
most readily through the larynx. Plastic dispos-
able catheters especially designed for this pur-
pose are available. However, an ordinary ure-
thral catheter serves very well. The catheter
is passed to the posterior nasopharynx and ad-
vanced quickly synchronous with inspiration
until the larynx is passed. Success will be the
reward of persistence. Signs indicating that the
catheter is propexly placed are apparent when:
( 1 ) the patient coughs due to the presence of
the foreign body, (2) he is unable to speak
above a whisper because the tube passes be-
tween the vocal coxxls, and (3) air may move in
and out of the catheter as the patient breathes.

Suction should be maintained for only brief
periods and is stopped by removing the thumb

Fig. la. Catheter entering the esophagus and illustrating
the advantage of an anterior curve in the catheter tip.
(b). Holding the tongue forward occasionally aids in pass-
ing the catheter to the trachea.

130

THE JOURNAL-LANCET

Fig. 8. Tracheotomy showing anatomic dead space re-
duced by about 75 cc.

from the open arm of the Y connector. The cathe-
ter is left in place during these periods of rest. At
each session, the intermittent aspiration should
be continued until there is no further return. If
the direction of the catheter's curve is known,
it can be passed into either main bronchus.

The effect of gravity on drainage of bronchial
secretion is well known and accounts for our
rather routine order to turn patients frequently.

A very important mechanism in maintaining
a clear airway is collateral respiration, which
allows air from a well-ventilated lobule of lung
to pass into an adjacent lobule whose bronchus
may be plugged. With the accumulation of air
peripheral to the block, the cough again becomes
effective in clearing the mucus. In cases in which
mucus or blood blocks a bronchus and causes
atelectasis of an entire lobe or lung, collateral
respiration cannot play a part in relieving the ob-
struction. In this circumstance, the body must
rely upon the action of the cilia and the pull of
gravity to dislodge the blocking agent. These
two mechanisms are often ineffectual and always
slow enough so that aspiration of the obstruct-
ing mucus is essential. This may often be ac-
complished by nasotracheal suction (figure 7),
and this bedside maneuver should be tried as
soon as the diagnosis is made. If this method
fails to accomplish re-expansion of the atelectatic
lung, bronchoscopy would ordinarily be con-
sidered as the next step. If bronchoscopy is not

available, however, or if repeated bronchosco-
pies are necessary, a tracheotomy should be
provided in order to clear the tracheobronchial
tree of mucus by suction as often as necessary.

From several viewpoints, a tracheotomy is an
extremely useful procedure in patients with chest
injuries. It has some disadvantages, but these
are outweighed in importance by its advantages
(figure 8).

Advantages:

1. Anatomic dead space is reduced by approxi-
mately 75 cc.

2. Resistance to air flow through the naso-
oropharynx and larynx is avoided with the result
that: (a) tendency to paradoxical motion of the
chest wall is minimized and ( b ) air leak from the
lung may be decreased.

3. Tracheal secretions may be aspirated as fre-
quently as necessary by the nurse.

Disadvantages:

1. Effective cough is lost and the patient must
rely upon his attendants to keep his airway clear.

2. The warming and humidifying action of
the nasal passage is lost, so that secretions tend
to dry and water loss may be excessive.

Indications for tracheotomy should be liberal,
but we must recognize that as we perform the
tracheotomy we assume certain obligations to
the patient. Among these are removal of tracheo-
bronchial secretions, prevention of excessive dry-
ing of the respiratory tract, and replacement of
fluid lost by virture of the tracheotomy.

SUMMARY

When a patient with an acute chest injury is
seen in the emergency room, an attempt should
be made to maintain circulation by replacing
blood loss as may be indicated by signs of shock
and controlling obvious points of hemorrhage.
Simultaneously, the factors concerned with the
mechanics of ventilation are considered. Of the
various measures discussed, placement of the
intercostal catheter, tracheotomy, and intercostal
nerve block are the procedures most often em-
ployed as lifesaving measures in the emergency
room. Frequently, these are the only measures
necessary to a good result. Laceration of the
liver or spleen is so commonly a part of any chest
injury that we must be extremely sensitive to
signs of intra-abdominal bleeding or evidence of
blood loss beyond that which is estimated from
the chest x-ray film or suction trap bottle to have
been lost into the chest. If there is even the
slightest question of intra-abdominal bleeding,
the patient’s cause is best served by exploratory
laparotomy through an upper abdominal mid-
line incision.

APRIL 1958

131

The Tuberculin Test

PAUL S. DODD, D.V.M.
Danville, Illinois

Forty years ago, a member of the Bureau of
Animal Industry made the following state-
ments to a veterinary college class: “We are
going to tuberculin test all the cattle in the
United States. We are going to eradicate bovine
tuberculosis." To envision the fulfillment of such
a stupendous undertaking at that time was be-
yond our comprehension. Yet, in one decade,
practically all the cattle had been tested at least
once. In two decades, 95 per cent of the counties
were accredited. In other words, we had re-
duced the incidence of reactors to less than 1/2
of 1 per cent.

Over 176 million tests had been made, and
more than 3 million reactors had been found and
slaughtered. In forty years, the disease has been
practically eradicated or, at least, reduced to the
minimum. For the fiscal year of 1956, over 9
million cattle were tested, with an incidence of
infection of only .15 of 1 per cent. In 1917, the
incidence of infection was 3.2, increasing to 4.9 in
the early twenties and gradually decreasing in
the succeeding years.

My personal experience as a student assistant
in tuberculin testing had been confined to the
old time consuming subcutaneous method where-
by 1 veterinarian could test only 40 to 50 head
of cattle in twenty-four hours. Therefore, the
goal outlined in the statement quoted seemed
somewhat exaggerated to me. But, the speaker
had predicted that a new, more reliable, and
much faster test would be available. He was, of
course, referring to the intradermal test which
had survived a period of experimental checks
and, since 1920, has been a widely accepted
method.

Every disease control program must have
many good reasons for its existence, and this one
was certainly no exception. Tuberculosis of the
food producing animals was at one time the most
serious disease with which the American farmers
were confronted. The meatpacking industry was
forced to condemn and destroy about 10 per cent
of their swine and beef carcasses because of
tuberculosis. Consequently, they either had to

paul s. dodd is Vermilion County veterinarian and
president of the Illinois Tuberculosis Association.

buy livestock at a cheaper price or subject it to
inspection. An economic problem existed affect-
ing both buyer and producer.

Cattle breeders and dairymen were becoming
more aware of the various dangers of the disease
and the benefits of disease-free animals both
from the beef and milk production standpoint.
Medical men and public health authorites were
cognizant of the fact that milk from infected
cattle was causing appreciable human infection
and loss of life, especially in infants and children.
Forty years ago, it was estimated that 11 per cent
of all infant tuberculosis was of bovine origin.

Realization of these facts resulted in the organ-
ization of the cooperative campaign for the con-
trol and eventual eradication of the disease. Led
by the Bureau of Animal Industry and joined by
the several state livestock sanitary officials,
groups of livestock breeders, and others inter-
ested in the livestock industry, a plan of opera-
tion was developed.

In order to facilitate the testing, definite plans
worked out by the Bureau had to be accepted.
The first involved choice of a uniform type of
tuberculin and a standard dosage. The second
concerned the matter of an indemnity to be paid
by the federal government for infected cattle
and to be matched by the cooperating state, as
well as other incidental expenses and activities
to be carried out by mutual agreement with
counties and other governmental agencies. The
meat packers added their support to the pro-
gram by offering a premium of $.10 per hundred-
weight on swine originating in an accredited
county.

Preliminary testing had been confined largely
to purebred herds on an individual herd basis
with the idea of reaching accredited status. How-
ever, in a very short time, serious consideration
was given to broadening this plan to a definite
region known as the area plan. The county was
used as a unit or area of operation, and counties
were encouraged to employ a county veterinar-
ian. All counties in all states did not adopt this
idea. However, the work was done by federal or
state-employed veterinarians who were assigned
temporarily to a county where men were not
regularly employed. To me, the area plan has

132

THE JOURNAL-LANCET

been a very significant and vital point in the
gradual eradication of bovine tuberculosis. With
this program, it has been possible to test all the
cattle in every county. The idea of having a local
man available and reponsible for the work in his
area was important. For operational purposes, we
divided the counties by townships and tested
each as a unit. We started in one corner of a
township and stopped at every farm on every
road until every herd in the township was tested.
This plan was followed until the county was
thoroughly canvassed. We generally employed a
local helper, a person acquainted in the area, who
not onlv assisted in handling the cattle for test-
ing but notified the cattle owner on the previous
day that we woidd be there and that he should
have his animals properly confined. I would like
to state that while these plans worked, they were
not always as simple as they may sound. In the
first place, a small percentage of owners were
not at all cooperative, and a considerable amount
of time was required to convince the farmers of
the efficiency of the program. In some instances,
a sheriff and his deputies were necessary to com-
plete the testing of recalcitrant owner’s cattle.
It was very discouraging to be met at the farm
entrance by a belligerent owner with defiance in
his eye and a shotgun in his hand. At that time,
many farms were not well equipped to handle
the cattle; barns and fences were often inade-
quate; and temporary facilities were often too
temporary.

The cattle in many instances were none too
cooperative either! Weather conditions could
often ruin the best laid plans. Roads in the early
days were quite often impassable. If conditions

I prevented working on planned injection dates,
the work could be postponed, but it was con-
sidered a cardinal sin not to make the readings
after the cattle had been injected. We walked
many miles through rain, mud, and snow to com-
plete the job. Sanitary surroundings on many
farms were far from admirable, and, in the case
of infected premises, we were often obliged to
enforce cleaning and disinfecting practices by
withholding indemnity payments until the job
was completed. A minor problem in some
localities, especially in small towns and suburban
areas, was the one-cow herd. They were hard
to find, but the local lay helper proved his value
in such situations. This factor was and continues
to be important, as the family cow was quite
often infected. We were as diligent in locating
and testing the single animal as the large herds.
To err is human, and we, no doubt, made many
mistakes. We have probablv condemned some
noninfected cattle, and we may have passed

some reactors. However, the ultimate results
seem to indicate that a highly satisfactory level
of performance was acquired and maintained.

Regularly employed veterinarians soon became
very efficient in making injections and readings.
Herd histories and physical conditions as well
as keen observation of sanitary surroundings,
food, and water supplies were significant. Post-
mortem reports on reactors helped the operator
judge future readings. Years ago, when the dis-
ease was more prevalent, we considered 10 per
cent of cases with no visible lesions a good
record. However, as the infection decreased, the
percentage of cases without visible lesions in-
creased. While this fact might cause the most
experienced operator some embarrassment, it is
not unusual, and we bave continued to use our
judgment and remove the animal from the herd.
In more recent years, we have become more
tolerant and do, on occasion, hold an animal in
isolation for retests before making a final de-
cision. Some generalized cases did not react to
tuberculin but were often removed from the
herd because of clinical symptoms observed by
the veterinarian. This was especially true in
herds with persistent infection where obscure
but certain infeetors were in evidence.

When an infected herd was found and reactors
removed, the herd was subjected to 2 sixtv-day
retests at least, more if infection persisted. In
many cases, 6 to 12 retests were necessary to
find and remove the last victim. These herds
were then generally placed on an annual test
basis until all possibility of further trouble was
eliminated. By doing this on each area retest, a
thorough follow-up was accomplished.

The 2 tests formerly used were the subcutane-
ous and the ophthalmic. The subcutaneous was
a thermal test. After 3 preinjection temperature
readings on each animal at two-hour intervals, a
quantity of tuberculin was injected subcutane-
ously. Beginning eight hours after the injection,
temperature readings were resumed at two-hour
intervals and recorded on a chart, together with
the preinjection readings and proper identifica-
tion of each animal. Five postinjection tempera-
tures were recorded. Reactions were indicated
by characteristic elevations in temperature ( rain-
bow-shaped on the chart) beginning at the
eighth hour and increasing 3 to 5° at about the
twelfth to fourteenth hour and then gradually
receding. No variation between the pre-and
postinjection temperatures constituted a negative
reaction or absence of infection.

The ophthalmic test was used to some extent
years ago, both in conjunction with the subcu-
taneous and the intradermal and also alone. It

APRIL 1958

133

was never considered very efficient and, because
of its many bad features, was finally discon-
tinued. The intradermic test is made by injecting
one minim of specially prepared tuberculin be-
tween the layers of skin of the caudal fold. Re-
actions are indicated by a noticeable swelling
at the injection site. These swellings may be
small as a pea, hard and circumscribed, or as
large as a hen egg. They may be soft and doughy
and diffused, with a feeling of unusual warmth,
but with no particular line of demarcation.

Routine testing can and does become rather
tiresome and boring. Were it not for the sincere
dedication to the ideal of eradication uppermost
in the minds of experienced operators, the pro-
gram would not have been so successful. How-
ever, complacency has no part in any disease-
control program. Just when we seem to have
sunk into an indifferent routine, we discover a
new and exciting case and with it a new surge
of enthusiasm for the work as well.

As the disease has diminished, the period of
accreditation has been extended. At present,
when the disease rate is less than 1/10 of 1 per
cent, the period for a complete retest is six years.
In some areas, even on some farms, that could
be too long. We try to keep closer observation
on those areas, but our greatest fear is that some-
where, sometimes an unusually virulent infector
may appear to destroy many animals and years
of hard work. Thus, we must forever be on the
alert.

Some of the complications encountered in our
program were due to infection from other than
bovine sources. Swine and avian infectors were
quite common in some areas, doubtless causing
false reactions on occasion, yet, such pronounced
reactions that the operator had to condemn the
animal.

Avian infection was found to be quite ex-
tensive in some areas of Illinois, and swine in-
fection was correspondingly high. There is no
known type of swine tuberculosis, so that species
was either infected by the avian, bovine, or
human type. In 1928, in a survey testing pro-
gram in one central Illinois county, 22 per cent of
the poultry over 1 year of age reacted to the
intradermal test. In another survey made on
poultry and swine on the same premises in one
county, swine infection was found to exist on
only one farm where poultry infection was not
found, and, in this particular instance, the swine
were new additions.

Field experience indicates that avian infection
can be contracted from the human being as well.
Gross lesions have been found in poultry on
premises harboring known cases of human tuber-

culosis. While not proved, it would seem poss-
ible that a chain of infectors from the human
being through the avian and swine to the bovine
and thence back to the human being can exist.

European studies have revealed that the bo-
vine type is sometimes responsible for open pul-
monary tuberculosis in man, and that man can,
in turn, spread the infection to the cows he
milks and cares for. However, if the type of in-
fection in man is of human origin, the danger to
the bovine is meager.

A report from Sweden blames a woman worker
on a large dairy farm as the infector of 47 head
of cows. This woman was suffering from pul-
monary tuberculosis, and the disease in the cattle
developed some ninety days after she was im-
ployed. In this instance, detailed laboratory tests
proved conclusively that the infection was of
human origin.

Just this last year, a dairy herd in one of our
Illinois counties suddenly disclosed several re-
actors.-On following through, it was found that
the herd owner had an active case of tubercu-
losis, and he was immediately hospitalized. Typ-
ing was inconclusive at last report.

One result of this incident was the adoption
of a resolution bv the Executive Committee
of the Illinois Tuberculosis Association, which
recommended that it should be mandatory for
all persons in contact with tuberculin positive
cattle to be tuberculin tested themselves, and, if
their reaction were positive, they should have
chest x-ray films taken and any other diagnostic
tests necessary to determine the presence of
active tuberculosis.

Our health and agriculture departments have
been notified of this action and have agreed to
cooperate in fulfilling the recommendation. Per-
haps some valuable and interesting information
may result.

We have encountered several instances in
which swine were responsible for a bovine out-
break. Probably one of the most interesting
cases of swine as bovine infectors was demon-
strated in LaSalle County, Illinois, a few years
ago. In a herd of 35 head of Guernsey cattle
which had shown no infection since 1941, 17 1
reactors appeared on the annual test; 16 head
showed lesions of tuberculosis on the post-
mortem report; and 6 head were condemned as
generalized cases. These cattle were all young,
between 2 and 10 months of age. On the first
sixty-day retest, 6 more reactors were found; 2
of them were condemned. All 6 were under 10
months of age. When the first reactors were
found, everyone concerned was quite interested
in finding the source of this unusual occurrence,

134

THE JOURNAL-LANCET

and, after some investigation, the swine herd was
regarded with suspicion. All breeding swine
were subjected to the intradermal test with bo-
vine tuberculin, and more than 40 of the 80 head
reacted. The entire swine herd was sold for
slaughter, and all subsequent retests on the re-
maining cattle have been negative. It was learned
that these young cattle had been confined with
the swine herd during the spring and early
summer. The adult cattle on the farm had never
been in contact with the swine herd or with
the young cattle which reacted.

Just a few years ago, we discovered 2 reactors
in a cattle herd of 4. There had been no pre-
vious infection on the farm. We held the animals
for retest, and they reacted again. They were
sent to slaughter but showed no macroscopic
evidence of tuberculosis. We tested the poultry
and the brood of 4 sows on the farm. Three of
the sows reacted; 1 was negative. Investigation
revealed that the 3 sows had been purchased
the previous year at a sale some distance away.
The poultry were negative.

Swine and avian exposure no doubt cause
some of the atypical reactions and account for a
percentage of the cases without visible lesions.
Yet, some are so impressive that they demand
radical action. Veterinary philosophy inclines to-
ward the preventive phase of disease control.
We would much rather remove a suspicious
animal from the herd than take a chance on leav-
ing future potential infectors.

Our friend, Dr. J. A. Myers, once said: “In
human tuberculosis, many problems which are
today considered controversial have already been
solved by the veterinary profession.”

I am not sure of all the specific problems to
which the doctor refers, but the fact that we
test all the cattle, remove them from the prem-
ises, and conduct a thorough follow-up are most
important.

These points pose an example for all workers
in the tuberculosis field whether veterinary,
medical, public health, nursing, or volunteer.
Our task may appear comparably simple and
easy, but I can assure you it never has been or
ever will be.

In the first place, organization with dedicated
leaders was necessary and an extensive educa-
tional program as well. Uniform methods of
operation with a standardized tuberculin in the
hands of trained personnel who were deter-
mined to accomplish the job at hand were of
prime importance.

As an active member of our countv and state
tuberculosis associations for several years, I have
had ample opportunity to observe the aims, am-

bitions, and problems of the professional and
voluntary workers. As is the case in any organi-
zation, there exists an honest difference of opin-
ion regarding the best methods necessary to
achieve the goal— the eradication of tuberculosis.

Perhaps my viewpoint concerning the efficien-
cy of tuberculin testing is somewhat different
from that of a medical man, but it would appear
that we could learn from one another. We know
what causes the disease, but we have no accept-
able preventive to date. Medical and surgical
treatment have reached a new high in efficiency,
reducing hospital confinement appreciably. I
will not quote statistics; they are available to
all. It appears then that the discovery of un-
known cases is the most difficult problem for
both doctor and veterinarian. Unless we use all
the tools at our command, we are not taking ad-
vantage of our opportunities, and, certainly, one
of the simplest tools is that of the tuberculin
test. I have noticed in recent years the increased
interest shown by various persons in the value
of the test and a more concerted effort on their
part to stimulate others to use it more carefully
as a case-finding tool. I have tried to listen ob-
jectively to all the arguments pro and con, but
I am convinced that if this tool were used wisely
and diligently, we would reap a harvest of pre-
viously undetected cases. Certainly, the results
of the bovine campaign have proved this point,
and I can think of no obstacles more formidable
than those the veterinarian has conquered.

I believe the medical profession and other
agencies should agree on a type of tuberculin
and standard methods of administration and ob-
servation. The Bureau did this for us and avoided
much confusion. I believe the general practi-
tioner lacks interest or is indifferent to the dis-
ease and the part they can and should take in
the eradication program. I have had physicians
tell me that we have had and always will have
tuberculosis. I’m quite sure that these pessimistic
physicians are very much in the minority, but,
since this is a medical problem, it will never be
conquered without the wholehearted support
of that profession.

Someone once said that to permit the death
of people from a preventable disease is a crime
against humanity. I don’t presume tuberculosis
to be a wholly preventable disease at this time,
but, certainly, early case finding will prevent
thousands of deaths, untold suffering, and save
millions of dollars.

It seems that a united effort between our pro-
fessional and voluntary groups could develop a
concerted program of case finding through the
use of the tuberculin test. Surely, a majority of

APRIL 1958

135

medical men would be interested in this eradica-
tion program if they were properly indoctrinated
from a reliable source. If we are to succeed in
our campaign, our educational endeavors must
start at the top with the medical profession. The
family physician must play a key role, lie, of
all people, wields the most influence with his
patients on medical problems. Without his in-
terest and advice no disease-control program can
succeed. It appears to me that the first job of
our voluntary associations is to enlist the cooper-
ation of every physician, acquaint him with the
problem at hand, and encourage him in any way
possible to use the tuberculin test in his private
practice as a diagnostic agent and make plans
for area testing programs where feasible. In
areas with organized medical societies, they
should take the lead in perfecting some type of
working group dedicated to finding every case
of tuberculosis in their respective areas.

This undertaking may appear to be an imposs-
ibility, a too comprehensive plan, and yet, in the
process of total eradication of tuberculosis, it
may become necessary to do more than we need
to do. One sure way of failing to eradicate this
disease is to do less than is required. I am not
unmindful of the other case-finding methods
available, and I most certainly encourage their
unlimited use. However, in view of the recent
adverse criticism of radiation from x-ray (war-
ranted or not), it seems a most appropriate time
to use the most basic of all methods— the skin
test.

Sometimes we cannot see the forest for the
trees seems a classic example of the truth and
reminds me of the story of the boy and the
puzzle. A father gave his small son a jig-saw
puzzle of a map of the world, thinking the task
of putting it together would keep him busy for
a long time. The father was surprised to find that
the boy did the job in a comparatively short
time and asked him how he did it. The boy re-
plied: “It was easy, there is a picture of a man
on the other side, I just put the man together and
the world turned out all right.”

Recently, a local pediatrician related an in-
teresting story. A 3-year-old girl developed some
enlarged lymph nodes in the cervical area. They
were not sensitive but noticeably enlarged and
rather hard. After several weeks of medical and
antibiotic treatment, no improvement was vis-
ible. On an intuition, the doctor used the skin
test for tuberculosis and got a positive reaction.
The nodes were surgically removed, and biopsv
proved them to be tuberculous. This is just an-
other example of finding the unknown case by
using the intradermal test as a routine diagnostic

procedure. A complete follow-up of contacts
has not been made at this time, but it is quite
enlightening to discover what results the small
red spot on a child’s arm may eventually pro-
duce.

I believe physicians and nurses have done
quite a lot of area testing in Minnesota with in-
teresting and profitable results. A group of St.
Louis physicians have also carried on a tuber-
culin testing program in St. Louis County, Mis-
souri, with most gratifying results. Several Illi-
nois counties are extending their school testing
projects. In our city, the annual school health
surveys, which formerly included the tuberculin
testing of the first, fifth, and ninth graders, was
extended to include the high school seniors.
Several formerly unknown contacts were dis-
covered, and one active case in a senior was
disclosed. The additional cost was negligible in
comparison to the results obtained. School sur-
veys, as such, may not appear too productive,
but they certainly make it possible to identify
the areas in which follow-up work should be
done. A map of our city was so pin pointed by
our sanatorium director, as a result of the school
survey, that it shows most clearly and graphically
where the disease is most prevalent. Plans are
being formulated to conduct a thorough case-
finding program in this specified area. If this
proves productive, other areas may likewise be
canvassed.

Another phase of the use of the skin test
which has received verv little attention is the
cost. From what I can learn, more active tuber-
culosis can be found much less expensively, es-
pecially in selected areas, by using this simple
test. In some cases, mass x-ray film surveys
exact a terrific cost with minimum results. I
am yet to be convinced that a skin-test program
in these same areas would not yield better results
at less cost. I believe it should be tried and
followed to the extreme potential.

Since tuberculosis is a very insidious disease,
there is, no doubt, more complacency regarding
its eradication. If it were half as spectacular as
poliomyelitis, it may well have been much nearer
eradication at this time. It seems rather ironic
to me that we have done so much more toward
eradicating tuberculosis from our bovine popu-
lation than from human beings.

Mrs. Edith Backs, executive director of Wash-
ington County, Illinois, had a most interesting
article in the January 1957 issue of Evcn/bodi/s
Health, entitled “Putting the Tuberculin Test
to Work.” I woidd like to quote her 13 reasons
for using the test.

1. When tuberculosis strikes infants, it is often

136

THE JOURNAL-LANCET

quickly fatal. That is why parents and baby
sitters should be tested.

2. Tuberculosis contracted during childhood
may “go to work” during adolescence. That is
why high school students should be tested.

3. Tuberculosis is the chief killer in the 15-
year-age level. That is why everyone in this
group should be tested.

4. Tuberculosis often disables for years. That
is why middle-aged persons with family responsi-
bilities should be tuberculin tested.

5. Tuberculosis may remain inactive for years
only to go on the warpath during old age. That is
why old people should be tuberculin tested.

6. Tuberculosis is especially troublesome when
teamed with diabetes. That is why diabetic per-
sons should be tuberculin tested.

7. Tuberculosis is very prevalent in many for-
eign countries. That is why returning military
personnel should be tested.

8. Tuberculosis is contagious and communi-
cable. That is why all contacts of a known case
should be tuberculin tested.

9. Tuberculosis germs are not revealed by
roentgenogram before they have done damage.
That is why even those who have negative chest
films should be tuberculin tested.

10. When someone in a household has become
infected, others in it may have picked up the
germs from the same source. That is why all in
the home should be tested if one reacts.

11. Tuberculosis can do serious damage with-
out causing symptoms. That is why those in
apparently perfect health shoidd be tuberculin
tested.

12. Tuberculosis can strike anyone. That is
why you should be tuberculin tested.

13. It is tme that many who harbor tubercu-
losis germs will never have trouble from them.
It is also true that no one harboring them is
ever safe. That is why every reactor should have
an annual chest x-ray film taken till he is 99/2
years old.

Yes, x-ray films will detect tuberculosis early,
but the skin test will find it much earlier and at
less cost.

The World Health Organization will hold its eleventh annual assembly
meeting in Minneapolis from May 26 through June 14. This is the first time
the group has ever met in the United States.

In honor of the occasion, The Journal-Lancet is proud to announce that
its June issue will be devoted to the accomplishments, objectives, problems,
and needs of the World Health Organization. Articles on public health written
bv outstanding world health authorities will be presented.

Copies of the Special Issue will be distributed to representatives and dele-
gates of WHO. These may be the only copies of an American medical journal
to be found in doctors’ offices, clinics, and hospitals in the far corners of the
world.

APRIL 1958

137

Tuberculosis from Man to Animals

GEORGE D. MORSE, M.D.
Peoria, Illinois

In the united states, the tuberculin testing of
cattle and the universal pasteurization of milk
have all but eliminated the danger of transmit-
ting tuberculosis from animals to man. The re-
verse, however, is not true. Man’s inability to
adequately subdue the disease in his own species
—although he is certainly equipped with enough
knowledge to accomplish this job— means that
susceptible animals live in constant danger of
catching tuberculosis. This article then will con-
sider principally the transmission of tuberculosis
from man to animals. This is not a minor prob-
lem either from the public health or economic
standpoint. Animals who contract tuberculosis
from man can later pass it on to other animals
and, thence, back to humans, thus acting as re-
servoirs of infection. Financial loss can be of
considerable concern. Ask a dairy farmer who
loses his whole herd without adequate compen-
sation; or, ask a zoo keeper who loses an entire
monkey colony.

Three types of tubercle bacilli must be consid-
ered: the human, bovine, and avian. Avian tuber-
culosis is quite common and is a serious disease
in many species of animals and birds. Only a
very few human cases have been reported in the
literature, and most of these have not been
proved. If avian tuberculosis exists in man, it is
extremely rare, and transmission of avian bacilli
from man to animals probably never takes place.
Differentiation between the 3 types of tubercle
bacilli existing in the warm-blooded animals is
based partly upon cultural characteristics but
mostly on the virulence test. The animals used
in the virulence tests are the guinea pig, rabbit,
and chicken. Frequently, the results of these
tests are inconclusive ( table 1 ) .

The most common domestic animals which
can be infected with tuberculosis are the cow,
pig, dog, cat, horse, and chicken. Each of these
will be discussed briefly. Either from reports in
the literature or from personal knowledge of the
author, the following is a partial list of additional
animals in which tuberculosis has been known to

george d. morse is medical director and superin-
tendent of the Peoria Municipal Tuberculosis Sana-
torium, Peoria, Illinois.

exist: guinea pig, rabbit, duck, goose, turkey,
peacock, pheasant, canary, parakeet, parrot,
guinea fowl, crow, goat, lamb, deer, fox, kanga-
roo, buffalo, mink, elephant, giraffe, striped
gopher, rat, mouse, badger, gnu, antelope, wild
boar, waterbuck, sparrow, squirrel, vole, baboon,
lemur, orangutang, chimpanzee and monkeys of
all varieties. Five groups will be discussed: wild
animals, domestic animals, pets, laboratory ani-
mals, and animals in the zoo.

WILD ANIMALS

Several statements in the earlier literature that
tuberculosis does not exist in wild animals in
their natural state are not true. Tuberculosis
has been reported in many species of wild
animals. The sparsity of these reports can easilv
be attributed to the fact that a wild animal with
tuberculosis is apt to become sick and incom-
pacitated rapidly. It is more likely that it would
succumb to some natural enemy before falling
into a pathologist’s hands. Incidence of the dis-
ease in wild animals would no doubt depend on
how closely they were associated to man.

DOMESTIC ANIMALS

Cow. Much has been written about tuberculosis
in cattle. The cow is susceptible both to the
bovine and human type, but practically all cases
occurring in cattle are due to the bovine bacilli.
Pathologically speaking, the lung is the principal
site of infection, although the liver, spleen, kid-
ney, mucous membranes, udder, and mammary
glands are frequently involved. The most com-
mon mode of transmission from cow to cow is
thought to be by droplet infection through
coughing or expired air. Bovine tuberculosis can

TABLE 1
VIRULENCE test

Tt/pe bacillus

Guinea pig

Animal

Rabbit

Chicken

Human

+

?

O

Bovine

+

+

O

Avian

?

+

+

+ = susceptible
? = slightly susceptible
O = resistant

138

THE JOURNAL-LANCET

be transferred from the cow to dairy workers,
and, in turn, they can transmit it hack to unin-
fected cattle. Even new herds can be infected
in this manner, resulting in serious losses. The
cow is susceptible to human tuberculosis but to
a much lesser extent. With few exceptions, it
is apparent that human tuberculosis in cattle is
a rather benign disease. It is doubtful whether
a cow suffering from human tuberculosis would
be infectious to other cattle or man either
through the milk or through close contact. But,
the tuberculin test would be positive, and, since
it is impossible to tell which type of tuberculosis
exists, the cow must of necessity be destroyed.
Personal communication from a former superin-
tendent of a midwest sanatorium revealed an in-
stance in which the garbage incinerator access-
ible to the sanatorium’s dairy herd was thought
to be the cause of many positive tuberculin re-
actions, and, when the situation was remedied by
fencing, no more trouble of this kind was en-
countered. Recently, a patient was admitted to
the Peoria Municipal Tuberculosis Sanitarium
with minimal active pulmonary tuberculosis. His
disease was discovered through a chest x-ray
film taken because he was the tenant supervisor
of a dairy herd which suddenly had developed
an epidemic of tuberculosis. Unfortunately, it
was never established whether he or the cattle
had human or bovine tuberculous infection.
However, it was assumed that it was bovine be-
cause of the extensive pathology found by the
meat inspectors in the cattle that were destroyed.
Bovine tuberculosis can be missed in a routine
sanatorium examination because the bovine ba-
cilli grow very poorly on the glycerinated cul-
ture media, which is almost universally used, and
in which the human bacilli thrive quite well. It
is suggested that guinea pigs should be used
along with the cultures, since the guinea pig
will be infected equally by both types. When-
ever cultures of a patient’s sputum are persis-
tently negative, but guinea pig inoculations are
positive, the bovine type of bacilli should be
suspected. All dairy workers should have pre-
employment x-ray films taken at regular inter-
vals during employment. Whenever a tuber-
culosis epidemic occurs in a previously unin-
fected herd of cattle, all human contacts should
be immediately x-rayed not only to see if they
are the source of infection but also to see
whether they may have contracted the disease
from the infected cattle.

Pig. Swine are susceptible to all 3 types of
tubercle bacilli. Tuberculosis in pigs is quite
common, but the majority of cases are caused
by the avian bacilli, which is due to the close

association of the swine in barnyards with chick-
ens and other poultry. Eating untreated garbage,
which frequently contains chicken entrails, is
another source. Bovine tuberculosis in swine has
become quite rare because of the corresponding
rarity of cattle tuberculosis. Human tuberculosis
does occur and is caused by eating human gar-
bage. Transmission of tuberculosis from man to
swine by personal droplet infection certainly
occurs infrequently.

Dog. Tuberculosis in the dog is much more
common than usually thought. Because of his
close contact with man, human tuberculosis is
far the most common type of disease, although
he is also susceptible to bovine tuberculosis but
rather resistant to avian. The disease in the dog
is apparently of a mild nature with few symp-
toms, but pathologic reports of autopsy material
leave no doubt that the dog with tuberculosis
should be considered a dangerous pet. The fact
that dogs have not been proved to have trans-
mitted tuberculosis infection to humans is prob-
ably due to the fact that few people have ever
realized that this is a possibility. Tuberculosis
workers should consider all household pets
whenever contact examinations are carried out.

Cat. Tuberculosis in cats is not common. Most
reports of the incidence of the disease in cats
have come from outside the United States, and,
whenever investigated, the vast majority of cases
were bovine. Experimentally, it has been shown
that cats are rather resistant to the human strain
but quite susceptible to bovine tubercle bacilli.

Horse. Tuberculosis in horses is quite rare,
and, when it occurs, it is almost always caused
by bovine bacilli. This rarity is not only ac-
counted for by the decrease in cattle tubercu-
losis, but the incidence in horses was quite low
even when tuberculosis in cattle was prevalent.

Chicken. All types of poultry are susceptible
to avian tuberculosis but are totallv resistant to
the human and bovine type. Chickens apparently
are the most susceptible, while turkeys, ducks,
and geese are less apt to have tuberculosis. The
human being plays no part in infecting the poul-
try by direct contact, but his inability to create
preventive measures can certainly be considered
an undesirable contribution, and any shortcom-
ings in this matter can frequently result in finan-
cial loss to man, not only because of sick chick-
ens but because of transmission of avian disease
to swine and other susceptible animals.

LABORATORY ANIMALS

There are several reports in the literature of
tuberculosis in laboratory animals, most of these
in monkeys. Before the use of isoniazid, tuber-

APRIL 1958

139

Fig. 1. Zoo director holding chimpanzee pre-
liminary to taking x-ray. X-ray cassette is under
director’s shirt.

Fig. 2. Roentgenogram of female gibbon ape.
Autopsy showed acute advanced pulmonary
tuberculosis.

culosis in laboratory monkeys almost always
meant the loss of the entire colony. Cough is
a predominant symptom in the monkey infected
with tuberculosis, and, consequently, through
droplet infection or dust inhalation, monkeys
in near or even distant cages become infected.
Spontaneous tuberculosis also occurs in guinea
pigs. Transmission of the disease from an in-
fected guinea pig to an uninfected pig in a
different cage is quite rare, probably because of
the absence of droplet infection. In the earlier
days when sanatoria made much use of the labor
of convalescent and former patients, occasional
cases of tuberculosis occurred in guinea pigs
which had contracted the disease from caretakers.

PETS

Many animals classified as pets can get tuber-
culosis from their human associates. Undoubted-
ly, tuberculosis in the pet monkey is one of the
principal causes of illness and death. A monkey
can catch tuberculosis very easily, becomes quite
sick, and always dies if untreated. Thus, a posi-
tive tuberculin test in an untreated monkey
means active tuberculosis. It has been shown
that certain birds are susceptible to other than
avian types of tuberculosis. Parrots and para-
keets have been known to be infected with both
human and bovine tuberculosis. If a veterinarian
suspects tuberculosis in anv pet, all human con-

tacts should be x-rayed. It is unwise for persons
with known positive sputa to own pets.

ZOOLOGICAL ANIMALS

Many animals in the zoo can be infected with
both human and bovine types of tuberculosis,
but the monkey is the principal victim. Very
few reports are found of the outbreak of tubercu-
losis in zoos, possibly because they have been
unrecognized or the zoo did not want the public-
ity. However, there is no doubt that it is a very
serious problem (figures 1 and 2).

Animals in the zoo that are most susceptible
are all varieties of monkeys, the hooved animals,
such as the elephants, giraffes, and camels and
the rodents. The cat family appears to be strong-
ly resistant. The following is an account of a
tuberculosis epidemic occurring in the Glen Oak
Park Zoo in Peoria, Illinois. Early in 1956, a
Dinah monkey became ill with respiratory in-
fection and died. An autopsy performed by the
zoo veterinarian and later confirmed by the
pathological laboratory at St. Francis Hospital,
Peoria, revealed far advanced pulmonary tub-
erculosis. In the next few months, tuberculosis
developed in 12 other monkeys. Ten either died
or were destroyed. The entire monkey colony
was tuberculin tested with 1 to 1,000 dilution of
old tuberculin, which is the dose recommended
in humans. All monkeys were found to be nega-

J O

140

THE JOURNAL-LANCET

tive, including those later proved to have tuber-
culosis. Treatment was started on the sick mon-
keys using the same doses of streptomycin and
isoniazid that are recommended for humans.
The epidemic continued and the treatment was
ineffective. Dr. Byron W. Bernard, chief veter-
inarian of the Zoological Society of Cincinnati,
and Dr. Leon H. Schmidt, Christ Hospital, In-
stitution of Medical Research in Cincinnati, were
contacted. The Cincinnati Zoo had had a simi-
lar epidemic, and Dr. Schmidt had done con-
siderable research in tuberculosis using monkeys
as laboratory animals. On advice of these men,
certain tuberculosis control measures were put
into effect. The two remaining monkeys sus-
pected of having tuberculosis are now well, and
no other cases have occurred for over a year.
Recommendations are as follows :

1. All zoo attendants should have pre-employment
chest x-ray films taken, and all employees of the park-
should have their chests x-rayed annually.

2. Whenever any animal becomes ill, especially with
respiratory infection, he should be removed from the
general zoo quarters and placed in isolation. Here, his
condition can be more easily diagnosed and treated.

3. Whenever an epidemic of tuberculosis is suspected,
all monkeys should be given a tuberculin test with old
tuberculin up to at least 1 to 10 dilution, which is 100
times stronger than the usual recommended dose for
humans. All positive monkeys should either be destroyed

or, if they are of sufficient value, treated. Monkeys under
treatment should be given INH (isoniazid), the dose
being 10 mg. per pound of body weight per day, which
is approximately 5 to 10 times the recommended dose
for humans. As a preventive, all other monkeys in the
zoo should be placed on 1/2 of this dose (5 mg. per
pound of body weight ) to be continued indefinitely.

CONCLUSION

The incidence of tuberculosis in animals is rough-
ly proportionate to the incidence of the disease
in man. Control of tuberculosis in animals de-
pends upon its control in man.

Several years ago, coinciding with the use of
the new antituberculosis drugs, it was freely pre-
dicted that tuberculosis will soon be eliminated.
Now, it appears that this prediction may be pre-
mature. The fall in the mortality rate is leveling
off, and, in many parts of this country, the in-
cidence, as measured by newly reported cases, is
actually increasing. The contagious, noncoopera-
tive patient is still with us, and, thanks to the
same miracle drugs, he is much more dangerous,
because incomplete or interrupted treatment has
increased his activities in time and breadth. Many
appeals have been made to do something about
this situation with little effect. It seems that many
fatal accidents must occur at a dangerous inter-
section before a traffic light is erected.

BIBLIOGRAPHY

1. Beattie, Margaret, and Nicewonger, R.: Bovine tubercle

bacilli in sputum. Am. Rev. Tuberc. 45:586, 1942.

2. Benson, R. E., Fremming, B. D., and Young, R. J.: Tuber-
culosis in monkeys. Am. Rev. Tuberc. 72:204, 1955. 18.

3. Brooke, W. S.: The vole acid-fast bacillus: 1) Experimental

studies on a new type of mycobacterium tuberculosis. Am. Rev.
Tuberc. 43:806, 1941. 19.

4. Carmichael, J.: Bovine tuberculosis in the tropics, with
special reference to Uganda, part I. J. Comp. Path. & Therap. 20.
52:322, 1939.

5. Cumming, W. M.: Pulmonary tuberculosis in dairy-farm 21.

workers and others coming in contact with cattle; type of
causal organism in 14 cases. Tubercle 14:205, 1933.

6. Dobson, N.: Tuberculosis of cat. J. Comp. Path. & Therap. 22.
43:310, 1930.

7. Feldman, W. H., and Code, C. F.: Tuberculosis in dogs, 23.
with report of a case in which surgical procedures may have
influenced the pathogenesis. J. Tech. Methods 22:49, 1942.

8. Feldman, W. H.: Animal tuberculosis and its relationship to 24.

the disease in man. Ann. New York Acad. Sc., 48:469, 1947.

9. Feldman, W. H., and Moses, H.: Human tuberculosis in a

bovine; case report of a spontaneous infection in an adult 25.
bovine. Am. Rev. Tuberc. 43:418, 1941.

10. Francis, T.: Tuberculosis in the dog. Am. Rev. Tuberc. 73: 26.

748, 1956.

11. Fremming, B. D., and others: Maintenance of a colony of
tuberculous monkeys. Proc. AVMA, 92nd annual meeting,

August 1955, pp. 219-222. 27.

12. Griffith, A. S.: Types of tubercle bacilli in equine tuber-
culosis. J. Comp. Path. & Therap. 50:159, 1937.

13. Grosso, A. M.: Tuberculosis in monkeys in Buenos Aires Zoo. 28.
Gac. vet., B. Aires, 18:9, 1956.

14. Hawthorne, V. M., and Jarrett, W. F. H., and others: 29.

Tuberculosis in man, dog, and cat. Brit. M. J. 2:675, 1957.
Abstracted in J.A.M.A. 166:287, 1958.

15. Hull, T. G.: Diseases transmitted from animals to man, in

Tuberculosis bv W. H. Feldman. Springfield, Illinois: Charles
C Thomas, 1955, p. 5.

16. Lovell, R., and White, E. G.: Naturally occurring tuber-
culosis in dogs and some other species of animals. I. Tuber-
culosis in dogs. Brit. J. Tuberc. 34:117, 1940. II. Animals
other than dogs. Brit. J. Tuberc. 35:28, 1941.

17. Mallick, S. M., Aggarwal, H. R., and Dua, R. L.: Investi-

gation into incidence and type of tuberculous infection in
cattle at Amritsar, with special reference to human infections.
Indian M. Gaz. 77:668, 1942.

Medlar, E. M.: Pulmonary tuberculosis in cattle; location
and type of lesions in naturally acquired tuberculosis. Am.
Rev. tuberc. 41:283, 1940.

Myers, J. A.: Man’s Greatest Victory over Tuberculosis.

Springfield, Illinois: Charles C Thomas, 1940.

Myers, J. A., and Dustin, Virginia L.: Cattle get TB from
People. Hoard’s Dairyman, Fort Atkinson, Wis., Dec. 10, 1947.
Plummer, H. C., and Brown, M. I.: A study of acid fast
bacilli recovered from tuberculous monkevs. Canad. J. Pub.
Health. 45:296, 1954.

Riser, W. H., and Karlson, A. G.: Tuberculosis in the dog.
J. Am. Vet. M. A. 129:118, 1956.

Schmidt, L. H.: Some observations on the utility of simian

pulmonary tuberculosis in defining therapeutic potentialities
of isoniazid. Am. Rev. Tuberc. Supp. 74:138, 1956.

Schmidt, L. H., Hoffmann, R., and Steenken, W., Ir.:
Pathogenicity of atypical chromogenic mycobacteria for the
Rhesus monkey. Am. Rev. Tuberc., 75:169, 1957.

Scott, H. H.: Tuberculosis in man and lower animals. Med.
Res. Council Special Report Series. 149:1, 1930.
Stadnichenko, A. M. S., Sweany, H. C., and Kloeck, J. M.:
Types of tubercle bacilli in birds and mammals; their inci-
dence, isolation and identification. Am. Rev. Tuberc. 51:276,
1945.

Stamp, J. T.: A review of the pathogenesis and pathology
of bovine tuberculosis with special reference to practical prob-
lems. Vet. Rec. 56:443, 1944.

Tice, F. J.: Man, a source of bovine tuberculosis in cattle.
Cornell Vet. 34:363, 1944.

Wood, A. J., and Kennard, M. A.: The feeding, housing and
management of a small monkey colony. Canad. J. Comp.
Med., 20:294, 1956.

PERSONAL COMMUNICATIONS TO THE AUTHOR

1. Dr. R. H. Runde, medical director, Peoria County Sanatorium
District.

2. Dr. R. B. Hollingshead, veterinarian, Glen Oak Park Zoo.

3. Mr. Richard Houlihan, director, Glen Oak Park Zoo.

4. Dr. James H. Steele, chief, Veterinary Public Health, U. S.
Public Health Service.

APRIL 1958

141

Edward A. Meyerding, M.D

Physician, Educator and Friend

By J. ARTHUR MYERS, M.D.

When Dr. Henry M eyerding came to the
United States from Germany in the 1850’s,
he located in New Ulm, Minnesota. He later moved
to St. Paul, where he not only practiced medicine
but also was assistant health commissioner and
served numerous terms on the school board. Later,
as a member of the state legislature, he supported
hills in the interest of public health, education, and
general welfare.

Born on Christmas Day, 1879, Edward A. Meyer-
ding had the advantages of observing his grand-
father and learning about his education, public
health, and practical medical work. As children, he
and his brother Henry were inspired to contribute
in a similar manner. Edward no sooner graduated
from the Mechanic Arts High School in St. Paul
in 1898 than he entered the University of Minnesota
School of Medicine and graduated in 1902. For the
next seven years, he was engaged in private practice.
He was especially interested in eve and ear work,
so, in 1909, he enrolled for graduate studies at the
Manhattan Eve, Ear and Throat Hospital and at
Bellevue Medical Hospital, New York City. From
there he attended the Harvard Graduate School and,
later, took special training in Chicago and Boston
and, still later, in Paris.

Upon returning to St. Paul to engage in this
specialty, his services were sought by the superinten-
dent of schools, and he became the first school
physician in that city. Among numerous other activ-
ities, he worked to provide special education for
children with defective hearing, vision, and speech,
as well as crippled and mentally slow individuals.
Results were so remarkable that by 1914 he was
made director of hygiene of the St. Paul schools.

Dr. Meyerding entered active military service in
the Medical Department of the United States Army
in April 1917. He was well prepared because, since

1898, he had served as a commissioned officer in
various capacities in the Minnesota National Guard
over a period of ten years. He was discharged in
1919 with the rank of major. On September 13,
1924, he was commissioned lieutenant colonel in the
Medical Corps of the United States Army and ad-
vanced to colonel on April 17, 1935. Since July 24,
1941, he has been colonel, inactive.

When he resigned from his school position in
1924, his departmental staff had increased from 1
nurse and himself in 1909 to 18 school nurses, 1
chief nurse, 5 provisional nurses, 3 oral, hvgienists,
6 medical examiners, and 37 teachers of special
classes.

In 1924, he was elected executive secretary of the
Minnesota Public Health Association and secretary’
of the Minnesota State Medical Association. This
was a splendid arrangement as it brought the two
organizations to a better understanding of one an-
other. During the next thirteen years, they were
developed beyond any height that had ever been
anticipated. Bv 1937, each had become large
enough to require a full-time secretary. Dr. Mever-
ding then resigned from the State Medical Associa-
tion position in order to devote his entire time to
the Tuberculosis and Health Association.

In 1924, 1,708 persons were reported to have
died from tuberculosis in Minnesota. This was a
mortality rate of 69.5 per 100,000. The 1 state and
14 county sanatoriums \\rere filled to capacity, and
many persons were ill in their homes for lack of
sanatorium beds. Dr. Meverding was determined
from the beginning to stop this terrible onslaught of
a disease which was already known to be prevent-
able. His first activity was to develop a compre-
hensive program. He then traveled hundreds of
thousands of miles bv automobile to effect good
organization of the people in every nook and cranny

142

THE JOURNAL-LANCET

of the state. He repeatedly visited these organiza-
tions to make certain a uniform program was main-
tained in all of the counties.

Being secretary of the State Medical Association
provided him an opportunity to promote tubercu-
losis work among the physicians throughout the
state. He organized a team of medical speakers,
and the local medical societies arranged programs
devoted entirely to talks on tuberculosis. Dr. Mever-
ding usually conveyed this team in his private auto-
mobile. Some of the meetings were as far awav
as 300 miles, and not infrequently the trips started
at noon, and, after the evening medical meeting, the
return trip required the remainder of the night.

Early and accurate diagnosis was given a promi-
nent place in the program. The specificity and accu-
racy of the tuberculin test were well-established.
Dr. Meverding, therefore, launched a tuberculin test-
ing program. It was accompanied bv an educational
campaign to inform the citizenry of the state of the
value of the test in locating persons who were
harboring tuberculosis germs and the importance of
periodic x-rav films of the chests of all persons who
reacted to the tuberculin test.

In 1932, he arranged for tuberculin diluted and
ready for administration to be delivered without
cost to physicians throughout the state who de-
sired it. This was on a demonstration basis, and
it proved so effective that the State Board of Health
adopted it in 1937 and has continued this fine
service to the medical profession.

In the early 1920’s, it had been recognized that
x-ray films usually reveal evidence of evolving gross
lesions in the lungs of tuberculin reactors earlier
than any other phase of examination. It was also
known that such lesions appear only in the lungs
of persons who react to tuberculin. Therefore, x-ray
film inspection should be routine procedure in all
chest examinations of tuberculin reactors and peri-
odical thereafter for those whose chests appeared
clear on initial examination.

A serious problem concerning the production of
satisfactory x-ray films was encountered. Many
physicians throughout the state had first class x-ray
equipment but were not producing satisfactory films.
Dr. Meverding made available an expert technician
who spent time in their laboratories demonstrating
satisfactory film technic.

In the early 1940’s, when the wave of enthusiasm
for mass photofluorographic surveys reached Minne-
sota, it had previously been established bv actual
studies in this state that such a program had in-
surmountable limitations, making it far inferior to
the procedures already in vogue. However, the pro-
motors of photofluorographic surveys created so
much enthusiasm that established facts made no
impression, and the surveys were introduced. Dr.
Meyerding took advantage of the opportunity to
cooperate purely on the basis of a device for bring-
ing the disease to the attention of the public and
better informing the people. However, tuberculin
testing in the schools and elsewhere with the usual

program was continued by his association and its
allies without interruption while the mass photo-
fluorographic surveys proceeded. In only a few
years, mass photofluorographic surveys ended ex-
cept in a few special groups, and the regular pro-
gram continued.

Dr. Meyerding has constantly emphasized the
importance of transmitting information about tuber-
culosis to professional as well as lay citizens. For
example, in 1928, he inaugurated refresher courses
in tuberculosis for practicing physicians. The
courses were usually held in sanatoriums. Fore-
noons and afternoons were devoted to examining
patients and demonstrating the best diagnostic and
treatment procedures of the time. The importance
of isolation to prevent infection of others was especi-
ally emphasized. Immediately following luncheon
and dinner, lectures were presented. Later in the
evening, a lecture was usually given for the entire
citizenry of the area. These courses were nearly
always oversubscribed.

In 1946, he arranged a three-day course in tuber-
culosis for lay workers at the Continuation Center,
University of Minnesota. This covered much im-
portant information about tuberculosis, which lay
persons could transmit to their co-workers through-
out the state. Those in attendance declared the
course so valuable that it was repeated the next year
with the same result. Ever since, this has been an
important educational activity.

In 1934, he arranged for the State Medical As-
sociation and the Tuberculosis Association to co-
operate in organizing a series of lectures on var-
ious health subjects, with special emphasis on tuber-
culosis, to be given bv physicians well qualified
in their respective fields. By 1938, four such lec-
tures were being presented annually in 20 colleges.
A tremendous amount of other educational work
has been done through pamphlets, newspapers,
magazines, radio, and television, as well as the
monthlv official publication of the organization,
Everybody’s Health.

Throughout the decades, Dr. Meyerding has made
the facilities of his organization available to, and
has worked in close cooperation with, about 40 other
organizations.

In 1940, the State Board of Health, the State
Medical Association, and the State Tuberculosis
Association decided to initiate a plan wherebv en-
tire counties might be accredited on the basis of
accomplishment in tuberculosis control. Standards
were set up and, whenever a county qualified, an
official certificate signed bv officials of these organi-
zations and the governor of the state was presented.
Lincoln Countv, the first to qualify, received its cer-
tificate on December II, 1941 (figure 1). In this
accreditation of counties, Dr. Meverding played
a large role. The program provided educational
opportunities that nothing else had done. The pro-
ject continues to operate and on April 1, 1958, 67
of the 87 counties had been accredited. Most of the
remainder are about to qualify.

APRIL 1958

143

MINNESOTA

DEPARTMENT OF -HEALTH

MINNESOTA STATE
MEDICAL ASSOCIATION

TfJm il fo (Oerfi^y fU

It in coin ©ount^J

Has fulfilled the minimum requirements of the Minnesota Department of
Health and the Minnesota State Medusa l Association for the control of Tuhercu-
losis, in consideration of which this award is granted and the County designated

A TUBERCULOSIS ACCREDITED COUNTY

Fig. 1. First certificate issued for accomplishments in tuberculosis control.

TB

ORTALITY RATE
Per 100.000

| | 10 or lea

[v]l0 + to!S

U 15+10 20
■ 20+10 25
[3 25+ to 30
SB 30+10 35

Hj 35 and up

Fig. 2. Map of Minnesota showing average
tuberculosis mortality rates in each county
over the five-year period, 1936 to 1940.

Fig. 3. Map of Minnesota showing average tu
berculosis mortality rates over the five-vear per
iod. 1952 to 1956.

144

THE JOURNAL-LANCET

Fig. 4. First certificate issued for tuberculosis control work in progress.

In 1940, a countv outline map of Minnesota was
produced showing the average tuberculosis mortal-
ity in each countv for the past five years. This was
widely distributed throughout the state and resulted
in the manifestation of a great deal of local pride
among citizens. The counties with a mortality rate
of 35 or more per 100,000 were indicated in black.
As a result of this map, so much interest was created
in the solution of the tuberculosis problem that activ-
ity in the program of eradication rapidly increased.
Thereafter, Dr. Meverding prepared a new map
every two years. Comparison of the maps over the
years enabled each citizen to visualize the effective-
ness of work in his countv as far as mortality was
concerned (figures 2 and 3).

When the Committee on Tuberculosis of the
American School Health Association decided to
certify schools with reference to tuberculosis activ-
ities in progress, a subcommittee of physicians was
appointed in each state. Minnesota was chosen to
make the initial demonstration, largely because its
workers had continued extensive tuberculosis work
in the schools over such a long period, and Dr.
Meverding was appointed chairman of the Minne-
sota subcommittee. He enthusiastically proceeded
with this project and with the other members of his
subcommittee made the demonstration a complete
success. The first official certificate was issued to
the schools of Northfield on October 15, 1945 (figure
4). This project also took advantage of local pride
and rapidly extended throughout the state. More
than 3,000 certificates have now been issued, and
many other schools are about to qualify. This pro-
ject has been adopted by several states with the
same good results. Wherever employed, this pro-

gram has stopped the tuberculous teacher, bus
driver, or other employee from spreading tubercle
bacilli to fellow workers and students. Moreover,
it has resulted in more activity and a more complete
program than any other procedure employed in the
state.

When Dr. Harold S. Diehl, dean of medical
sciences, University of Minnesota, instituted the
hospital admission examination for tuberculosis at
the University Hospital in 1935, Dr. Meverding
was immediately enthusiastic, and, through his or-
ganization, he began to inform physicians, hospital
administrators, nurses, and all concerned through-
out the state of the value of this procedure. There-
fore, it was not by chance that bv 1958 all but one
hospital in the twin cities required admission ex-
aminations, and 80 per cent of all persons entering
hospitals throughout the entire state now receive
such examinations.

Dr. Meverding is an indefatigable worker.
Throughout the years, he has devoted far more time
to his work than his position demanded. This ac-
counts in part for so many outstanding achieve-
ments. He has always had more than usual ability
in selecting staff workers. They are too numerous to
present individually in this sketch. Suffice it to say,
they have contributed mightily to the success of his
program. It has been said that the name Meverding
is synonymous with Christmas Seals in Minnesota.
Since becoming executive secretary of the Minnesota
Tuberculosis and Health Association, he has been
fully aware of the educational value of Christmas
Seals. In 1922, of all states, Minnesota ranked 12th
in the per capita sale of seals. With Dr. Mever-
ding’s efforts, Minnesota had reached eighth place

APRIL 1958

145

in 1928, fourth in 1942, third in 1947, and second in
1948. This position has since been maintained.

The tuberculosis mortality rate decreased from
69.5 per 100,000 (1,708 deaths) in 1924 to 3.6 (117
deaths) in 1956. The number of clinical cases de-
creased, so several smaller sanatoriums have been
closed, and the remainder are operating at about
50 per cent capacity. Tuberculosis infection has de-
creased among citv grade school children from 47
per cent in 1926 to 4 per cent in 1954. There are
now many schools in rural areas with no tuberculin
reactors.

Dr. Meyerding holds membership in county,
state, and national medical associations. He was an
organizer of the Minnesota Trudeau Society and
holds membership in the American Trudeau Society
and the National Tuberculosis Association. He is a
fellow of the American College of Chest Physicians.
In 1938, he was president of the Mississippi Valley
Conference on Tuberculosis. He has served on
numerous committees of that organization and of the
National Association of Tuberculosis Secretaries. In
1942, he was selected as Man of the Year bv the
4-H Clubs, and, in 1956, he received the William
G. Anderson award by the American Association for
Health, Physical Education, and Recreation.

It has been my privilege to travel extensively
with Dr. Meyerding bv automobile in the state
and by rail and airplane to many of the large centers

of the country attending conventions. We have
conferred hundreds of times concerning methods of
attacking and destroying the tubercle bacillus.

Throughout this intimate association of more than
a third of a century, he has constantly proved his in-
tegrity, sincerity, and ability. He always manifested
a strong courage of his convictions. Anv individual
or group who threatened to harm his well-thought-
out program or the cause for which he worked had
to be prepared to do battle. His fight against tuber-
culosis took precedence over everything else in his
life. He placed his organization behind every worth-
while tuberculosis control activity and has been re-
sponsible for the completion of many projects which
otherwise would have been left unfinished.

To Ed Meyerding belongs much credit for out-
standing achievement in tuberculosis control. Much
that is being accomplished today would not be
possible without the years of preparatory work
which he directed. When he retired on April 1,
1958, one of the most active and productive careers
in the fight to exterminate tuberculosis in this coun-
try’s history was closed. For well-nigh a third of a
centuryi he was one of America’s most powerful
forces against this disease. Fortunately, fires he
kindled in many others are still burning brightly.
From them others will be lighted, and, thus, the
goal so clearly visualized bv Dr. Meverding mav
be realized bv other generations.

Plans are under way for the Special Issue which will be published in June
in honor of the eleventh World Health Organization Assembly meeting to be
held May 26 through June 14 in Minneapolis. Serving as a channel of com-
munication on an international basis, the June issue of The Journal-Lancet
will afford an unusual opportunity to become acquainted with the health prob-
lems of many nations.

The Journal-Lancet is happy to be an avenue of information concerning
the outstanding work of WHO and the important personalities responsible for
this movement.

146

THE JOURNAL-LANCET

Cancet Editorial

Radiation Hazards

The article in this issue entitled “Ionizing Ra-
diation in Medicine — A Useful Tool and a
Hazard,” by Drs. Marvin, Loken, and Mosser is
very timely. This editorial is written to call atten-
tion to their article and to emphasize some aspects
of safe fluoroscopic and radiographic examinations.

Among the group of doctors with whom I am per-
sonally acquainted in this area — Minnesota, North
Dakota, and South Dakota — 2 have died of leu-
kemia within the last five years, undoubtedly due
to too much radiation. One physician died of metas-
tases from a carcinoma of the finger secondary to
radiation damage of the hand because he did not
wear lead rubber gloves during fluoroscopy.

Many patients in the states served by this maga-
zine have had to undergo plastic surgery for radia-
tion damage to the back caused bv too prolonged
fluoroscopic examinations, inadequate filtration in
the fluoroscopic tube, or both. It, therefore, be-
hooves us as doctors to protect ourselves, aides, and
patients from too much radiation.

Film monitoring badges should be worn bv all
personnel in all x-rav departments.

We must not order or perform unnecessary x-rav
examinations, but all indicated radiographic examin-
ations, I believe, can be performed safelv without
danger to the doctor, technician, or patient if the
proper safety precautions are observed.

We must do everything possible to minimize the
total exposure to all concerned. The equipment must
be properly installed with proper lead protection in
the walls and an adequate lead protected booth for
the operator. All equipment should be checked for
radiation hazards by a competent person at periodic
intervals. All radiographic diagnostic units should
contain at least 2 mm. aluminum filter. The smallest
possible cones should be used.

Fluoroscopic units should contain at least 2'A mm.
aluminum filter. Older fluoroscopic units with short
tube tabletop distance should be discarded or re-
built. The fluoroscopist must take sufficient time to
become adequately accommodated. He should use
as small a field as possible at all times and should
not use over 3 to 4 milliamperes of current. The
fluoroscopist must wear rubber gloves and an apron.
The gloves and apron should be checked period-
ically for cracks and leaks. Lead gloves and aprons
provide only partial protection. The fluoroscopist
must, therefore, keep his lead-gloved hands out of
the x-ray beam as much as possible.

A fracture should never be reduced under the

fluoroscope. The patient is exposed to much less
radiation from multiple films, and the doctor who is
reducing the fracture is in no danger. All fluoro-
scopic units should be calibrated to make sure that
the output at the tabletop is not over 10 r per min-
ute. All fluoroscopes should be equipped with a
timer that will shut off the equipment automatically
at the end of three to five minutes.

Films should be substituted for a fluoroscopic ex-
amination whenever possible. Multiple films prob-
ably give more information than a fluoroscopic ex-
amination. When necessary, a very short fluoroscopic
examination can be done, supplemented with films,
so total exposure to the patient is kept at a minimum.

Fluoroscopic examinations in children should be
performed only when a very good indication exists
and then should be completed in as short a time as
possible. Routine fluoroscopic examinations of chil-
dren’s chests should be abandoned. It has been re-
ported that a five-minute fluoroscopic examination
performed on a child doubles the chance that leu-
kemia will develop during his lifetime.

In infants and children with a condition such as
Perthes’ disease or congenital dislocation of the hip
that will require numerous x-ray examinations, the
gonads should be covered with lead on the follow-
up radiographic studies.

X-ray examinations of the abdomen of pregnant
women should not be done, except under extremely
urgent circumstances. X-rav pelvimetry should be
used onlv when it cannot be determined by clinical
means whether the pelvis is adequate or when some
abnormality is suspected. A study in England has
shown that the incidence of leukemia in children is
doubled bv an x-ray pelvimetry examination before
delivery.

The advisability of continuing 70 mm. photofluoro-
graphic chest survey programs has been discussed in
many lay and medical articles in the past few months.
Recently, James E. Perkins, M.D., managing director
of the National Tuberculosis Association, published
a paper on this subject. He concluded that if a per-
son had a 70 mm. photofluorographic chest examina-
tion every year from the age of 15 to 30, he would
have received a total of less than 1 per cent of the
amount of radiation exposure considered safe.

I, therefore, believe it advisable and safe to con-
tinue chest photofluorographic surveys in all areas in
which the vield is significant.

H. Milton Berg, M.D.,
Bismarck, North Dakota

APRIL 1958

147

The Last Tubercle Bacillus

This issue of The Journal-Lancet contains a
highly significant paper entitled “The Tuber-
culin Test” by Dr. Paul S. Dodd and another on
“Tuberculosis from Man to Animals” by Dr. George
D. Morse. They are important to all who visualize
the eradication of tuberculosis and to those who
should acquire such a vision. The authors make it
clear that the attack must be made on all three
pathogenic forms of tubercle bacilli, inasmuch as
each tvpe produces progessive disease in more than
one species. For example, the human type, in addi-
tion to man, causes clinical tuberculosis in such ani-
mals as primates, swine, dogs, and parrots, which
may disseminate their bacilli not only to other ani-
mals but also to people. Since the human type pro-
duces sensitivity of tissues in cattle, it is obvious
that this form must be sought in animals as well as
in people.

Although among the 95 million cattle of this
country, veterinarians and their allies have reduced
the incidence of those harboring tubercle bacilli to
0.156 per cent, cattle are still in considerable danger
of becoming infected from people. Those cattle
which are infected with the human type of bacilli
may react to tuberculin and, therefore, must be
sacrificed even though their lesions do not become
clinical.

The problem will never be solved if tuberculosis
work is limited to human beings, as they may be in-
fected with the bovine tvpe of tubercle bacilli ac-
quired not only from cattle but also from dogs, cats,
swine, parrots, and other animals.

While there are onlv slightly more than two dozen
known cases of authentic clinical tuberculosis caused
by the avian type of tubercle bacillus in man, this
subject has never been thoroughlv investigated.
Therefore, it is possible that the problem is more
serious than has been suspected. The very fact
that definite cases have occurred is sufficient reason
to support the veterinarian’s campaign to eradicate
the avian type of tubercle bacillus. It produces
clinical disease in fowl and other species, such as
swine, and, thus, is a serious economic problem.

This emphasizes the necessity for close coopera-
tion between veterinarians, physicians in human
medicine, and every interested group in making the
all-out eradication attack on the tubercle bacillus.
Failure to do this in the past has been costly in re-
tarding progress.

There are so many diseases transmissible from
animals to people and vise versa that every board
of health and tuberculosis association, state and
local, should have one or more veterinary members.

Veterinarians have led the wav and are so far
ahead of physicians in human medicine in tubercu-
losis eradication that their counsel should be sought
continuously. The example set in Illinois is one
that should be emulated and emploved everywhere.

Dr. Dodd has long been an active member of the
Illinois Tuberculosis Association and has served on
important committees. Now he is president of that
organization. He tells how veterinarians went from
farm to farm through rain, snow, and mud as well
as during clement weather, so that every animal in
a township, county, and state would be tested with
tuberculin. It made no difference whether there was
1 or 50 animals on a farm; all were tested. More-
over, periodic testing of cattle has continued among
the 95 million animals in this countrv despite the
fact that, in some places, such as the upper midwest
states, 5,000 or more tests must be administered to
find one reactor.

When this thoroughly organized program was
introduced on a nation-wide basis in 1917 and pro-
secuted to the nth degree, no such consideration was
given to the tuberculosis problem among people.
Only recently have physicians, nurses, and their
allies organized to visit each home in a township,
a county, or a state to find every person harboring
tubercle bacilli.

In 1917, physicians in human medicine had the
same tools as veterinarians, but they were hampered
bv theories, personal opinions, speculation, and the
like. Fortv years passed (1917-1957) with the veteri-
narian unceasingly promoting his program, while
the physician in human medicine continued to labor
over such questions as what does the tuberculin
reaction mean? which kind of tuberculin and which
method of administration should be emploved? The
threadbare statement “you can slaughter the cattle,
but you can’t slaughter people” was parroted. The
result is that even twenty years of the veterinarian’s
program brought such achievement as to be desig-
nated “man’s greatest victory over tuberculosis,” and
the next twenty vears were no less spectacular. In
1957, onlv 0.156 per cent of the nation’s 95 million
cattle were harboring tubercle bacilli, and apparent-
ly some of them were infected bv their human as-
sociates. Trailing in the far distance is the physician
in human medicine with a record of approximately
33 per cent of the 173 million people harboring
tubercle bacilli, among whom thousands are break-
ing down with clinical disease annually and often
disseminating tubercle bacilli to others.

Only in recent years have a few persons been
able to obtain adequate support to certify schools
with reference to tuberculosis work in progress and,
thus, make them safe from the standpoint of disemi-
nation of tubercle bacilli. Onlv a few have won
support for offering the tuberculin test to people
of all ages on countv-wide or municipal-wide bases
and, in this way, locate all the tubercle bacilli re-
siding in the area and act accordingly.

Veterinarians have shown that there is no short
cut to eradication of tuberculosis. There is no effec-
tive immunizing agent. There is no drug vet avail-

148

THE JOURNAL-LANCET

able to destroy bacilli in the animal or human tissues
such as we have for some other micro-organisms.

If a thoroughly germicidal drug becomes avail-
able, in all probability it will be of no help in
destroying all tubercle bacilli in the bodies of per-
sons now harboring them. Thev are secure in ne-
crotic avascular areas, so that cure of the disease
in the sense of killing all tubercle bacilli in the
bodies of such persons will remain a forlorn hope.

To catch up with the veterinarian will require
longer than forty years, because the life span of
people is much greater than that of domestic ani-
mals and because every infected person must be
kept under close surveillance throughout the re-

mainder of his life span. This means that if we
allow infants to become infected, the period of sur-
veillance must be continued for seventy or more
years on the average.

There is nothing to be gained but much to be lost
in continued procrastination. The onlv method now
available that offers the slightest hope of ultimate
eradication of tuberculosis consists of locating all
tubercle bacilli in both people and animals and out-
witting them until the last one has vanished. The
goal is far off but is attainable bv the methods des-
cribed by Drs. Dodd and Morse.

J. Arthur Myers, M.D.

Minneapolis, Minnesota

Clinical Gastroenterology, by Eddy
D. Palmer, M. D„ F.A.C.P.,
1957. New York: Paul B. Hoeber,
Inc., 630 pages, 216 illustrations.
$18.50.

When anyone writes a book of this
size, the interested reader usually
has three impressions: (1) how much
the author knows about the subject;
(2) how much the author does not
know about the subject, and (3) how
much remains to be learned about it.

The title of this book might well
have been Clinical Gastroenterology
Viewed From the Standpoint of an
Internist. Certainly there are phases
of gastroenterology which could not
be well discussed by anyone other
than a surgeon who affects a special
interest in the alimentary canal and
its appendages.

One cannot read this book with-
out appreciating that its author is a
good observer and an astute clini-
cian. Moreover, it is a very readable
book. The active cooperation of an
experienced surgeon or surgeons in
dealing with some of the disorders
treated in the text would undoubt-
edly have enhanced the value of the
monograph considerably.

How myopic some of the views
of the author are is readily detected
in the section on gastric cancer.
Concerning surgical management,
he says: “Surgical help is required
for the relief of pyloric obstruction,
for control of the unusual cases of
severe hemorrhage, and for what-
ever help is possible in cases of
acute perforation.” Under the cap-
tion of Philosophy of the Gastric
Cancer Problem as it Stands Today,
the writer says: “It seems clear that
we should give up current measures
directed at cure as a bad job now,
without waiting for a more effec-

tive replacement. A degree of emo-
tional and physical comfort is all
that can be promised the patient
at the moment. It at least repre-
sents a retreat from the current
blind track which is necessary be-
fore the right track can be found.
A doctor should consider well his
responsibility to avoid being fright-
ened into unleashing the whole pack
of therapeutic hounds against the
cancer as a way out for himself but
not necessarilv the patient.”

However much we lament the
circumstance that the surgical man-
agement of gastric cancer is not
what it should be, there is after all
a definite accomplishment. When
the writer suggests that 10 to 15
per cent of untreated patients with
gastric cancer survive five years or
more beyond the period at which
symptoms first appeared, he obvi-
ously is recording an experience un-
familiar to most of us who have a
real interest in this problem. A 10
to 15 per cent five-year survival is
the meager accomplishment, which
surgical clinics attacking the prob-
lem vigorously are reporting. And
however small that accomplishment
is, it certainly far surpasses the sur-
vival of patients left to their own
resources. In this clinic, no untreat-
ed patients with gastric cancer have

survived five years after the ap-
pearance of symptoms. This is dan-
gerous philosophy, which the author
of this book is preaching — a cir-
cumstance too which indicates how
much he is in need of active sur-
gical collaboration in a monographic
assault upon the problems of clin-
ical gastroenterology.

It is an easy matter to detect a
few weaknesses in a monograph
covering so wide a range. It is in
many respects a very informative
text, interestingly written, which
will have a wide appeal especially
among those who do not expect too
much of surgery or of surgeons.

Owen H. Wangensteen, M.D.

•

Fundamentals of Clinical Neuro-
physiology, by Paul O. Chat-
field, M.D., 1957. Springfield,
Illinois: Charles C Thomas, 392
pages. $8.50.

The author states in the preface that
the book is meant to present a global
view of the subject for the use of
nonspecialists in the field of neuro-
physiology. This view, he says, will
be influenced by the author’s vary-
ing interests in the different sub-
jects. This is, of course, true of any
book written by only one author.

In this case, however, we find a
fairly well-balanced emphasis on all
the important parts of neurophysi-
ology. The fundamental principles of
the subject are very clearly stated in
a didactic and stimulating fashion.

The problems of nerve conduction,
propagation of impulse, and synaptic
transmission are discussed at the be-
ginning. This is followed by a review
of the physiology of receptor organs
in general and in particular. One
chapter deals with the physiology of

APRIL 1958

149

skeletal muscle, briefly mentioning
the technic of electromyography and
discussing in a synthetic and clear
way the probable functions of the
small fiber system of the ventral
roots.

The rest of the book is devoted
to the central nervous system, start-
ing with the spinal reflexes, postural
coordination, and going on to dis-
cuss the physiology of the vestibular
apparatus, basal ganglia, and cere-
bellum and cerebral cortex, includ-
ing thalamocortical relationships.
Here, the specific and diffuse pro-
jection systems are mentioned, and
the different steps that lead to our
actual knowledge of these systems
are summarized. The final chapter
is a brief review of the facts concern-
ing the central representation of the
autonomous nervous system and the
neurophysiology of emotions.

The chapter on the nervous con-
trol of breathing is particularly im-
portant. This part needs a special
mention, not only because of the
clinical importance of the matter in
any specialty of medicine or phys-
ology, but also because of the
author’s vast knowledge of the sub-
ject. Dr. Chatfield has published
several papers on his experimental
findings regarding this problem, and
this chapter is a clear and intelligent
synthesis of the work of many out-
standing workers.

References are listed separately at
the end of each chapter, and the in-
dex of authors is long and quite
complete, considering the size of this
volume.

One criticism that can be made is
about the fact that proportionally
much greater emphasis is placed on
the first part of the book dealing
with peripheral nerve and general
neuro- and electrophysiologic prob-
lems than on the physiology of the
central nervous system, especially in
regard to the cortex, thalamus, and
basal ganglia. Interesting new find-
ings like those referring to the role
of dendritic potentials in the spon-
taneous cortical activity are barely
mentioned. Many interesting possi-
bilities about the role of the diffuse
projection system of the thalamus are
not extensively treated.

This, however, is probably in
keeping with the general scope of
the book. We can definitely say that
the goal of producing a short, clear,
and very well presented picture of
the physiology of the nervous sys-
tem for the purpose of teaching stu-
dents and newcomers to the field
was amply accomplished. The author
himself tells us in the preface that
the problems for which answers are
not yet clear are deliberately omitted.
It is only because we wanted to
read more about them in the same
clear and simple style in which Dr.
Chatfield writes throughout his book,
that we found ourselves missing a
more complete discussion of certain
central nervous system problems.

This book is definitely worth-
while for teachers and those inter-
ested in learning about the nervous
system.

Fernando Torres, M.D.

•

The Early Diagnosis and Treatment
of Acoustic Nerve Tumors, by J.
Lawrence Pool, M.D., and Ar-
thur A. Pava, M.D., 1957. Spring-
field, Illinois: Charles C Thomas,
161 pages. $5.50.

This monograph represents a review
of the acoustic nerve tumors in which
the authors utilize 6 previously re-
ported series of cases in addition to
a series of 122 cases of acoustic nerve
tumors operated upon at the Neuro-
logical Institute of New York during
the years 1944 to 1955.

History, terminology, histogenesis,
pathology, and incidence are all
dealt with categorically, albeit, in
some cases, briefly. Symptoms and
signs are chronologically reviewed
with emphasis upon the preponder-
ance of primary complaints and find-
ings referable to eighth nerve in-
volvement. The incidence and chron-
ologic order of appearance of head-
aches, cerebellar involvement, cranial
nerve involvement, increased intra-
cranial pressure, and terminal in-
volvement are thoroughly discussed
and a complete description of the
variation of signs and symptoms
attendant upon these conditions is
included. Diagnostic procedures,
such as skull roentgenograms, air en-

cephalography, arteriography, elec-
troencephalography, examination of
the cerebrospinal fluid, and audio-
metric and vestibular tests are de-
scribed, and the authors comment on
their opinion of the value of each
procedure. There is a section contain-
ing the histories of 6 atypical cases
in the author’s series and another
concerning differential diagnosis.

However, the most interesting and
valuable part of the monograph is
that devoted to discussion of the
surgical approach to the neoplasm.
The authors present a rather con-
vincing case for attempts at total
removal whenever possible. The en-
tire surgical technic is elaborated
upon and is accompanied by a num-
ber of illustrations. Moreover, sev-
eral subtle refinements of surgical
technic, such as partial resection of
the cerebellum and sparing of the
facial nerve, are described.

The authors conclude with sections
on postoperative management; mor-
bidity, including immediate post-
operative complications and later
sequelae, a discussion of the tech-
nic of facial nerve anastomosis; and
an analysis of the mortalities in their
series.

David F. Mendelson. M.D.

•

It Pays to Be Healthy, by Robert
Collier Page, M.D., 1957. New
York: Prentice - Hall, Inc., 285

pages. $4.95

It pays to read “It Pays to Be
Healthy.” This unique book de-
scribes in an excellent manner mod-
ern medicine in modern industry. Bv
paying attention to the health of the
individual, benefits come to both
employee and employer. Dr. Page
supports his statements by interest-
ing case reports which add a great
deal to the value of the book.

The last chapter on retirement is
especially good and is very helpful
in preparing for that day when the
tempo of life must change.

This book is to be recommended
with enthusiasm to physicians, pa-
tients, and all people interested in
the preservation of health.

Arnold S. Anderson, M.D.

150

THE JOURNAL-LANCET

Section on PAIN

Comments concerning this Section, criticisms, or suggestions for papers will be most
welcome. Physicians are cordially invited to submit articles pertaining to pain for
consideration. All inquiries and manuscripts should be sent to Dr. John S. Lundy,

102 Second Avenue Southwest, Rochester, Minnesota, or to the Editorial Depart-
ment, The Journal-Lancet, 84 South Tenth Street, Minneapolis, Minnesota.

Pelvic Pain in Women— a Universal Problem

G. F. DOUGLAS, M.D., G. F. DOUGLAS, JR., M.D,

G. C. DOUGLAS, M.D., W. W. DOUGLAS, M.D., and
SARAH F. DOUGLAS, M.S., M.T.

Rirmingham, Alabama

This title indicates that, not only the gyne-
cologist and obstetrician, but the internist,
urologist, proctologist, and general surgeon are
concerned with the problem of pelvic pain in
women.

Nerves that supply the ovary are derived from
the renal and aortic plexuses and accompany
the ovarian vessels in the tissue of the suspensory
ligament of the ovary. Embryologically, they
arise high in the abdomen and receive their
nerve supply from a source other than the pelvic
viscera. Pain of ovarian origin is often due to
the stretching of the covering of the ovary, which
disturbs circulation. As a rule, tumors of the
ovary, either benign or malignant, cause very
little pain in their incipiency.

Pains originating in the ovary, such as mittel-
schmerz, should be diagnosed, particularly if
this pain comes about the middle of the cycle
or the ovulation period. The gynecologist should
be a skilled diagnostician, for his diagnostic acu-
men will enable him to treat the pain wisely
rather than to do radical surgery early.

Tumors of uterine origin are, as a rule, asymp-
tomatic. When symptoms do arise, they are prob-
ably due to pressure on and adherence to sur-
rounding structures or from secondary changes
in the tumor itself.

Carcinoma of the body of the uterus or of the
cervix rarely causes pain until lesions have me-
tastasized or the contiguous nerve structures

From The Department of Gynecology, Medical
College of Alabama, Division of the University of
Alabama, Birmingham.

have been involved. One of the frequent causes
of abdominal pain may be from a postabortal
process which could involve the uterus primarily.
Not the rule, but, in some instances, considerable
pain follows procidentia, such as discomfort in
the lower pelvis. Associated with this there may
be an enteroptosis or descent of the pelvic viscera
which causes pulling on the intra-abdominal con-
tents with some discomfort.

Painful menstruation, or dysmenorrhea, is a
symptom rather than a true pathologic finding or
cause. The cause of this abnormal manifestation
of pain should be ferreted out very carefully by
a study of the different systems — neurologic,
gastrointestinal, and urologic — and other so-
matic factors. After all of the factors have been
ruled out, and, if the pain is neurogenic in origin,
an excision of the superior hypogastric plexus
of nerves, such as done in Cotte’s operation, often
gives complete relief. Rut, if there are causes
outside the uterine cavity or other pathology,
we need not expect this operation to produce a
cure. The so-called membranous type of dysmen-
orrhea is usually characterized by severe pain
and the passage of shreds in the menstrual blood
which, at times, amount to a complete cast of the
uterine body.

One of the severe types of pain in the pelvis
is that of ruptured ectopic pregnancy. Of course,
this condition occurs most frequently in the fal-
lopian tubes and can rarely be diagnosed by the
catastrophic pain at the time that rupture takes
place. One of our more simple diagnostic pro-
cedures is cul-de-sac tapping by which the blood
obtained does not clot. This finding, as a rule,

APRIL 1958

151

Section on PAIN

leaves very little doubt concerning the diagnosis
if other symptoms have preceded it, such as
pain, shock, skipping a period for a short time,
and so forth. When considerable loss of blood
accompanies this disturbance, it is well to obtain
a determination of the prothombin time which, if
excessively prolonged, may be combated by the
intravenous administration of vitamin K. Trans-
fusions of whole blood may be necessary. The
treatment of choice is immediate surgery.

A condition that should not be overlooked in
pain of the pelvis, which might be more of a
chronic nature, is the varicocele or the vari-
cosities of the veins about the broad ligaments.
This occurs much more frequently than is cor-
rectly diagnosed. When varicosities are present,
a thrombophlebitis often originates in the pelvis
and then extends into the legs. The operation
for varicocele provides a simpler and safer
method of relieving the pelvic pain than many
other accepted operative measures. So, if a cor-
rect diagnosis can be made early, the patient will
probably be relieved of pain without requiring
much more hazardous surgery.

Pelvic pain is frequently associated with pelvic
lesions in which an ovarian cyst is found, sudden
hemorrhage accompanying rupture of ectopic
pregnancy, rupture of a corpus luteum cyst in
which bleeding follows, or pelvic inflammation.
In a study at the Mayo Clinic of pelvic pain as
related to endometriosis, it was found that 54
per cent of the patients with pelvic endometriosis
had no pain. Some of the rarer findings in the
pelvis should not be overlooked. You may have
actinomycosis along with granulomatous disease
of the pelvis. I would pause for a minute to call
attention to the occasional case of ectopia of
the ureters distal to the internal urethral sphinc-
ter at which there is continous leakage. It is
congenital in origin and is often overlooked
until a study is done.

Abnormal vaginal bleeding not associated with
pregnancy should not be disregarded. Vaginal
examination should be done when the patient
presents herself to the physician with a history
of bleeding, rather than later when the period
has ceased. Oftentimes the bleeding is due to
a carcinoma of the cervix or of the fundus. If
diagnosed at once, the patient’s life can probably
be saved, whereas, if deferred, she has no chance
of recovery.

Different individuals have very different de-
grees of threshold levels of discomfort. Severe
pain to one individual might be discomfort to
another, so that, in evaluating the degree of

severity, we must have some idea of the pain
threshold of the individual.

Chronic residual pelvic inflammation of the
reproductive structures may provoke pain over
the years. The differentiation of acute salpingitis
and appendicitis is not always easy, and it is
generally believed that chronic appendicitis does
not occur nearly as frequently as was formerly
thought. In many instances, pathology other
than the appendix is involved. For example, pain
in the urinary tract might be diagnosed appendi-
citis, whereas it might be pvelitis, ureteritis,
stricture of the ureter, or, in some instances, a
stone in the urinary tract. Finallv, a pyogenic
type of pelvic inflammation usually involves the
serosa and wall of the fallopian tube, less often
the mucosal lining.

In our endeavor to differentiate or arrive at a
proper etiology of the pain in the fallopian tubes,
we should not overlook tuberculosis, for this con-
dition occurs more often than we realize. The
per cent of tubercular salpingitis, as a causitive
Factor in sterility studies, differs in various parts
of the country. Some say it occurs as often as 5
per cent. These statistics are Dr. Albert Shar-
man’s of Glasgow, Scotland. However, in many
places, it is no more frequent than to 1 per cent
or 1/2 per cent. In other countries, the statistics
run as high as 15 to 20 per cent. However, with
the eradication of tuberculosis of the chest and
other portions of the bodv, one would naturally
expect tubercular salpingitis to decrease.

In making a differential diagnosis of a rup-
tured ectopic pregnancy with other causes, in
probably 80 to 90 per cent of the cases, the
patient has missed her menstrual period. This
may have been for two weeks, or six to eight
weeks, but a good or satisfactory history of
menstruation and other factors often aid in a
correct diagnosis.

As stated before, an ovarian neoplasm does
not always produce early pain, but, if it is a
solid tumor, it should be regarded as possiblv
malignant and warrants an early operation.

We should not overlook the so-called somatic
abdominal pelvic pain. A number of people
come under this category, but, certainly, thev
should not be classified as such until all known
pathology that may be present has been ruled
out.

Certain individuals with pelvic pain can be
relieved by either sympathectomy, as previouslv
stated, or intraspinal alcohol injections. The
latter is given more commonlv with the intract-
able pain associated with carcinoma of the

152

THE JOURNAL-LANCET

Section on PAI N

uterus, particularly of the cervix. The pelvic sym-
pathectomy or the removal of a part of the sym-
pathetic nerve plexus or presacral neurectomy, in
which the presacral or the superior hypogastric
plexus is removed, is not a serious operation.
However, proper diagnosis should be made be-
fore operating or the results will be disappoint-
ing.

In a study of 5,539 patients, Guerriero and
Stuart found the chief complaint of pain was in
the region of the pelvis. These men stated that
there were 1,371 cases either of gynecic origin or
simulating such pain. Five hundred and seventy
one, or 41.6 per cent, of these women actually
had pelvic pain of other than gynecic origin, and
800, or 58.4 per cent, had gynecic states to ex-
plain the origin of their pain. They stated that
only 10.6 per cent of their cases required major
surgery for relief of their pain.

The management of severe dysmenorrhea and
pelvic pain is a problem now as it was in 1852
when Marion Sims stated “of all the newly found
drugs, not any is of much value to the woman
with severe pain except laudanum.” In other
words, he was stating that a drug to relieve
women of pain was considered, rather than a
diagnosis of its cause.

As late as 1921, Leriche made a complete study
of the pelvic sympathetic system in its relation to
pelvic pain, and he developed the procedure of
periarterial sympathectomy of the internal iliac
arteries. Four years later, in 1925, Cotte found
that the same results could be obtained by re-
section of the superior hypogastric plexus. Cotte,
as mentioned before, called the superior hvpo-
gastric plexus the presacral nerve.

Cervicitis, the pain of labor in its first stage,
and retroumbilical (not umbilical) pain of ap-
pendicitis are visceral pains, deep seated, ill
localized, and with no somatic component.

The rupture of a corpus luteum may present
a clinical picture essentially similar to that of a
ruptured follicle except that the time of onset of
menstruation is different. Many women with
bilateral pelvic pain do not have pelvic inflam-
matory disease. Pelvic cellulitis is seen most fre-
quently in puerperal patients, and it often occurs
in nonpregnant patients after uterine or cervical
instrumentation.

Rupture of a tubo-ovarian abscess is a verv
serious condition. Often, the patient becomes
profoundly ill in a very short time before the
peritonitis develops that will cause demise. Lapa-
rotomy is done with the principal aim of estab-
lishing intraperitoneal drainage, and the intes-

tines should not be greatly disturbed. Adminis-
tration of blood, fluids, antibiotics, and so forth
should be relied on largely for the treatment.

Severe abdominal pain may arise from neo-
plasms which have undergone torsion, with
hemorrhage into the tumor which might rupture.
Late pregnancy often results in placental infarc-
tion that can simulate a placental separation.
Pains may be of intragenital origin, in which the
pelvic lesions responsible are recognizable, or
they may be extragenital, in which normal pelvic
organs are present. The cervix is rather insensi-
tive to pain, and tenacular forceps can frequently
be placed on it without too great a discomfort.

In the later years of life, many women suffer
a bearing down sensation or a “weight in the
pelvis,” which is due to a cystocele, rectocele, or
uterine prolapse. In cases of secondary pain or
dysmenorrhea, endometriosis should not be over-
looked. Endometriosis is one of the most in-
capacitating of the chronic pelvic pains. Some
of the other causes of pains that may be associ-
ated with gynecologic pathology are the extra-
genital type other than pelvic varices, relaxation
or strain over the sacroiliac joints, diverticulosis
found in the bowel, backache often due to con-
stipation, and pain caused by orthopedic prob-
lems.

Pelvic pain is a prominent symptom in many
pelvic lesions, and its interpretation requires
careful investigation. But, we should make care-
ful study of all the systems relating to the pelvis
—the gastrointestinal, the genital, urinary, neuro-
logic, and psychosomatic.

It has been stated that pain is now accepted as
a sixth and separate sense, quite apart from the
so-called primary senses of sight, hearing, taste,
smell, and touch. Visceral peritoneum is often
and is usually insensitive to local stimuli, such as
pricking, cutting, or pinching. However, anv
pull on a mesentery or attaching a viscus to the
abdominal wall will cause pain.

The nerve supply to the pelvic organs include
the bladder, perineum, vulva, vagina, and anal
regions included in the types: (a) somatic or
cerebrospinal, (b) sympathetic, and (c) para-
svmpathetic. Thus, excision of the superior hypo-
gastric ganglia or presacral nerves may relieve
primary dysmenorrhea.

Pain from the pelvic viscera reaches the
consciousness of the individual through somatic
afferent nerve fibers called the viscerosensory
nerves, which pass upward from the pelvic vic-
cera in the sympathetic chains. Some theories
set forth concerning the etiology of pelvic pain

APRIL 1958

153

Section on PAI N

have been mentioned, such as chronic metritis,
chronic salpingitis, chronic appendicitis, adhe-
sions, congestion, psychoneurosis, and ovarian
dysfunction. Under the syndrome of ovarian dys-
function, vve have pelvic pain, menorrhagia,
metrorrhagia, cystic ovaries, tender ovaries,
tender uterus, dyspareunia, infertility, and ner-
vous exhaustion.

Considerable discomfort or pain may arise from
disturbance of the functions of the bones, joints,
muscles, ligaments, and fasciae of the trunk
pelvis and lower extremities.

A clinical method of measuring the motion of
intrapelvic pain is presented by Pitkin.

Pelvic myalgia is a term coined to describe a
painful spasm of the piriformis group of muscles.
The muscles that are affected either singularly
or in groups are: (1) piriformis, (2) inferior
gemellus, (3) superior gemellus, (4) obturator
interims, (5) gluteus medius, (6) levator ani,
and (7) coccygeus. Myalgia is one of those con-
ditions causing pain, not usually found in the
pelvis, and the pain probably would not be ex-
aggerated by careful digital examination. Powell
states that about 10 per cent of these cases are
made worse by massaging the pelvis. Pelvic
myalgia is not a clinical entity, but is a compli-
cation of posterior urethritis, an anal or rectal
pathologic condition, or an orthopedic defect.

In 1921, Leriche introduced periarterial sym-
pathectomy of the internal iliac (hypogastric)
artery for the relief of pelvic pain and obtained
good results. As previously stated, in 1924, Cotte
found that by sectioning the superior hypogastric
plexus (presacral nerve of Latarjet) equally good
results were obtained as those obtained by
Leriche. In 1913, Latarjet described and named
the presacral nerve as a distinct nerve.

It is unfortunate that so many patients, and
far too many doctors, are imbued with the idea
that the only solution to many of the ailments of
women, especially chronic pain and discomfort
in the abdominopelvic region, is surgery. We
might add that women who complain of chronic
lower abdominal pain are “pushed around” medi-
cally and surgically speaking much more than
any other group of patients. Pelvic treatment
should be largely conservative unless there is a
definite indication for the removal of the organs,
such as uteri, ovaries, tubes, and so forth.

Somatic innervation applies both to the sen-
sory and the motor nerve supply to the frame of
the body. As is known, a spinal nerve arises from
a segment of the spinal cord and is composed of
an anterior (motor) root and posterior (sensory)

root. In the posterior sensory root is found the
spinal ganglion in which are located the nutrient
cells of the sensory apparatus. This ganglion will
be mentioned in connection with the so-called
sympathetic sensory nerves. After a short course
as a single nerve trunk, each spinal nerve divides
into anterior and posterior branches, which con-
tain both sensory and motor components. Thirty-
one such spinal nerves — 8 cervical, 12 thoracic,
5 lumbar, 5 sacral, and 1 coccygeal — are present
on each side of the body.

Visceral innervation is effected by the auto-
nomic or involuntary nervous system. Below the
sacral promontory, the superior hypogastric plex-
us becomes the middle hypogastric plexus, and
the latter divides at the level of the first sacral
vertebra to form the bilateral inferior hypogas-
tric plexuses.

One of the most trying problems in gynecology
is presented by the patient who relates a history
of pain for which the physician can find no satis-
factory organic cause. Minor deviations from
absolute normal, such as freely movable retro-
displacement of the uterus, cervical hypertrophy,
or a slightly enlarged ovary may be the cause of
the difficulty.

As you will remember, Menninger has pointed
out that surgery is often sought bv patients who
fear something more than they fear surgery.
Many physical symptoms find their underlying
cause in the operation of emotional disturbances
upon the autonomic nervous system. Emotional
factors may play the same role in the production
of so-called tension or migrainous headaches.
Wolff has shown that migraine headaches are
vascular in origin and develop in 3 distinct
phases :

1. The vasoconstriction phase, which is brief
and does not cause pain.

2. The vasodilation phase, which is the imme-
diate cause of pain in that pain sensation struc-
tures surrounding certain vessels are stretched
or pulled upon.

3. The edema phase, which follows the vaso-
dilation phase and lasts a considerable length of
time.

Pain is generally described as organic or func-
tional but might better be distinguished as soma-
togenic and psychogenic. In the development
of a psychosomatic disorder, there are 3 requi-
sites. (1) a psvehoneurotic predisposition, (2)
an exciting emotional conflict, and (3) restriction
of outward expression of the conflict.

It is estimated that pelvic pain accounts for
at least 35 per cent of the admissions to a

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Section on PAIN

gynecologic ward. The urologic system should
never be overlooked in differentiating obscure
pains in the pelvis or the lower abdomen, especi-
ally if they are of a chronic nature.

Mengert has given a very workable classifica-
tion of pain, the general headings of which are:

1. Pain of genital origin, such as gonorrhea,
pelvic inflammatory disease, pelvic cellulitis, and
hemorrhage.

2. Uterine prolapse, adhesions, and twisted
pedicle of ovarian cyst.

3. Periodic distention of endometrial implant.

4. Tumor incarcerated in the pelvis.

5. Rupture of uterus, tube, or bladder.

6. Pelvic neurosis.

7. Pain originating in other pelvic structures,
such as: (a) the sacroiliac, (b) urinary tract,
and (c) intestinal tract.

A retrodisplaced uterus is not considered a
cause of pelvic pain nearly as frequently as it
formerly was. There is little clinical or patho-
logic similarity between adenomvosis and the
large “chocolate cyst” of the ovary.

Some of the gynecologic diseases causing pel-
vic pain might be listed as: (1) cervicitis and
parametritis, (2) uterine enlargements, (3) pel-
vic endometriosis, (4) malpositions of the uterus,
(5) pelvic congestion, and (6) adnexa disease.
Cervicitis is manifested by erosion, hypertrophy,
eversion, cystic change, and enlargement. En-
largement of the uterus causes backache and ab-
dominal pain because of pelvic congestion from
the stretching of supportive ligaments.

Endometriosis of the pelvic viscera rates high
in the classification of gynecologic causes of pel-
vic pain. Gynecologists are becoming more aware
of this condition and are diagnosing it much
more frequently than in former years. The pres-
ence of tender, cul-de:sac nodules, a retroverted
tender uterus and fixed adnexa, lower abdominal
pain, dysmenorrhea, and dyspareunia offer strong
evidence that endometriosis is present. Howard
Taylor describes a condition that he names the
“congestion fibrosis” syndrome, in which pain is
caused by vascular and tissue congestion in the
pelvic structure.

In the treatment of pelvic pain, first, the cor-
rect diagnosis should be made if possible, and,
second, each point of pathology should be recog-
nized and treated accordingly. In endometriosis,
which causes so much pain, Greenhill and others
have suggested that testosterone be given in
doses of 25 mg. three times weeklv for four
weeks. After a rest period of three to four weeks,
this therapy is repeated.

In summary, let us say that every case of pel-
vic pain should receive a careful evaluation,
which may require two or more office examina-
tions and that no rule should be adhered to ab-
solutely. Each patient must be treated individu-
ally.

CONCLUSIONS

1. Pain brings women to their physicians more
frequently than any other cause. Pelvic pain is
responsible for the greater per cent of these visits.

2. Ovulation may be a cause of pelvic pain
more often than is diagnosed.

3. Carcinoma of the uterus or the body of the
cervix is usually asymptomatic.

4. Ruptured ectopic pregnancy is the cause of
severe pain associated with shock.

5. Thrombophlebitis may cause pain in the
pelvis or broad ligaments and should not be
overlooked.

6. Tuberculosis of the tubes should be con-
sidered in making a differential diagnosis of pel-
vic pathology.

7. The sympathetic nervous sytsem often plays
a great part in the pelvic pain of women.

8. Nerves supplying the pelvis and urinary
region include 3 tvpes: somatic or cerebrospinal,
sympathetic, and parasympathetic.

9. Myalgia is a condition not usually found in
the pelvis, which affects certain muscles.

10. “Congestion fibrosis” is a newly described
syndrome, which Howard Taylor has been work-
ing on for a number of years. He feels that it
is a cause of pain more frequently than is recog-
nized.

11. Pain caused by stones, strictures of ureters,
and urinary type infection should always be
eliminated before radical surgery is performed
in the patient whose condition has not been satis-
factorily diagnosed.

BIBLIOGRAPHY

1. Bigelow, W. A.: A study of the results obtained by section
of ovarian vessels and adjoining tissue in relief of certain
types of pelvic pain. Canadian M.A.J. 47:233, 1942.

2. Counseller, V. S.: Gynecologic symptoms of major impor-
tance to the physician in general practice. Chicago M. Soc.
Bull. 56:50, 1953.

3. Greenhill, J. P. : Relief of pelvic pain by sympathectomy
and intraspinal alcohol injections. J. Internat. Coll. Surgeons
10:218, 1947.

4. Guerriero, W. F., and Stuart, J.: Pelvic pain of gynecic or
other origin. Am. J. Ohst. & Gynec. 67:1265, 1954.

5. MacFarlane, K. T.: Pelvic pain. Canad. M.A.J. 55:267,
1946.

6. Mussey, R. D., and Wilson, R. B.: Pelvic pain. Am. J. Ohst.
& Gynec. 42:759, 1941.

7. Pitkin, H. C.: Orthopedic causes of pelvic pain. J.A.M.A.
134:853, 1947.

8. Powell, N. B.: Pelvic myalgia: complication of posterior
urethritis in males and females. J. Urol. 62:245, 1949.

APRIL 1958

155

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EDITOR’S NOTE

The paper, “Pelvic Pain in Women— a Univer-
sal Problem,” by Gilbert Douglas and associates,
which appears in this Section on Pain should be
of considerable interest to all readers, since the
condition at one time or another afflicts every
woman patient and, thus, constitutes a problem
to the physician who sees her.

Comments on this Section on Pain, criticisms,
and suggestions for papers will be most wel-
come. Physicians are especially invited to sub-
mit papers on subjects pertaining to pain for
consideration. All inquiries and manuscripts
should be sent to Dr. John S. Lundy, 102 Sec-
ond Avenue Southwest, Rochester, Minnesota,
or to the Editorial Department, The Journal-
Lancet, 84 South Tenth Street, Minneapolis,
Minnesota.

John S. Lundy, M.D.

Book Reviews on Pain

INHALATION ANALGESIA IN CHILDBIRTH, by
E. H. Seward, M.A., D.M. (Oxon.), F.F.A.R.C.S.,
D. Obst. R.C.O.G., consultant anaesthetist, High Wy-
combe Group of Hospitals; and R. Bryce-Smith, M.A.,
D.M. (Oxon.), F.F.A.R.C.S., first assistant, Nuffield
Department of Anaesthetics, University of Oxford,
1957. Springfield, Illinois: Charles C. Thomas, 58
pages. $1.50.

This small book has compressed within it much infor-
mation about the use of analgesia in childbirth. The work
is intended primarily for the instruction of midwives,
which means that the text necessarily had to be made more
explicit than would be the case in a book planned for
those with formal training in the subject. This objective
has been attained.

The chapter on nitrous oxide presents concisely a
considerable amount of historical facts and practical in-
formation about that agent. Trichloroethylene is well
covered. There are chapters on causes of failure and on
devices for administering nitrous oxide and air and also
one on apparatus for administration of trilene and air.

There is a brief index. The regulations reproduced in
appendices 1, 2, and 3 govern the use of analgesic agents
and gas-air machines by midwives as well as rules re-
stricting the practice of midwives. This book is excellent.

John S. Lundy, M.D.

HYPNOGRAPHY: A STUDY IN THE THERAPEUTIG
USE OF HYPNOTIC PAINTING, by Ainslie
Meares, MBBS., B. AGR. SC„ DPM., 1957, Spring-
field, Illinois: Charles C. Thomas, 271 pages. $7.75.

This hook describes an aspect of hypnosis that is differ-
ent.

John S. Lundy, M.D.

Current Literature on Pam

A STUDY OF HYPODERMIC NEEDLE POINTS, by

F. Franz and R. M. Tovell: Anesthesiology 17:724-

729, 1956.

“Because of the introduction of new therapeutic agents
requiring subcutaneous, intramuscular, or intravenous in-
jection, the procurement of new needles and syringes
has become a source of increasing expense to hospitals
and physicians. At Hartford Hospital, over 60,000 needles
have been procured in the last three years. During that
period, demands placed upon the purchasing agent have
increased by 50 per cent to the point where 1 needle is
required per bed approximately ever)' ten days. The
cleaning, packaging, sterilizing, and issuing of needles
to wards from central supply constitutes a major effort
that is complicated by problems of collection and re-
sharpening prior to processing for reissue. It is with the
problem of resharpening that we are concerned in this
communication ....

“The needle shapes which are satisfactory are those
combining both strength and sharpness of cutting edge.
Onlv 2 of the samples examined satisfy both these cri-
teria . . 7 . One of these is a hypodermic needle point in
its original form as received from a manufacturer ....
The other .... is the point selected for development
of a mechanical needle sharpener .... Both the
needle and the grinding wheel rotate. It is so designed
that as the needle rotates it lifts away from the wheel in
order to preserve the cutting edges of the bevel. A con-
vex bevel is produced and hooks curled backwards from
the beveled surface are ground away.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 67. Copyright by John S. Lundy.

•

FACIAL NERVE PARALYSIS AFTER GENERAL

ANESTHESIA, by j. E. Fuller and D. V. Thomas:
J.A.M.A. 162:645,' 1956.

“Attention has frequently been drawn to the danger that
exists of producing damage to peripheral nerves in the
unconscious patient by stretching or by pressure

“ Case 1. A 54-year-old woman was undergoing ehole-
cystectomy; she was moderately obese and her neck was
short. During the induction of nitrous oxide-oxygen-ether
anesthesia, upper respiratory obstruction developed . . .
This was only partly corrected by insertion of a rubber
oral airway, but it was fully relieved when the lower jaw
was lifted forward by bilateral digital pressure applied
behind the angles of the mandible .... When the
patient recovered consciousness, she was noticed to have
a weakness of the left comer of the mouth, involving
both the upper and the lower lips, and there was flac-
ciclity of the left cheek .... The disability gradually
lessened, and after three months full function had re-
turned.

“Case 2. A 53-year-old man was being operated upon
for inguinal herniorraphy; he was of heavy build and had
a thick, short neck. Early in the induction of anesthesia
with nitrous oxide, oxygen, and ether, obstruction of res-
piration at the pharyngeal level occurred. Because place-
ment of a rubber oral airway failed to relieve the condi-
tion completely, forward digital pressure was applied
behind the mandibular angles, and breathing was thereby

156

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improved .... The next day, while shaving, the pa-
tient noticed that when he opened his mouth the right
corner became pulled toward the midline .... Recov-
ery was complete in three weeks ....

“This emphasizes the need for early tracheal intuba-
tion in patients whose airway can only be maintained by
strong pressure applied to the lower jaw. These appear
to be the first such cases reported in the English-language
literature.”

From John S. Lundy and Florence A. McQuillen: Anesthesia

Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 68. Coyright by John S. Lundy.

•

VOMITING AND REGURGITATION DURING AND

AFTER ANESTHESIA. SOME CAUSES, EFFECTS,

PREVENTION AND MANAGEMENT, by John

Adriani: J. Am. A. Nurse Anesthetists 24: 231-238,
1956.

“Few happenings are as disconcerting to an anaesthe-
tist as persistent postoperative emesis .... The prob-
lem resolves itself into two phases: diat of emesis during
anaesthesia and that of emesis in the postanesthetic
period .... The majority of fatalities on the operating
table are due to asphyxia. Aspiration of vomitus, blood
and other secretions account for more than half the
asphyxial deaths .... Vomiting is an active response in
which some voluntary effort is involved. Regurgitation is
passive and involves no voluntary effort ....

“Impulses which initiate vomiting may originate in
almost any part of the body because the vomiting center
is in communication with many nerves from many areas
. . . . Many of the drugs used in anesthesia, particularly
the narcotics and the general anesthetics, may stimulate
the vomiting centers in the medulla .... Regurgitation
not only occurs without voluntary effort but even when
the vomiting center is depressed. Vomiting, on the other
hand, does not occur if the vomiting center is depressed
by anesthetics ....

“The management of the patient with a full stomach
has been a matter of debate for sometime .... When
surgery is urgent and the operation must proceed, the
best expedient is to effect a rapid induction with cyclo-
propane or Pentothal with a muscle relaxant. Intubation
of the patient using a cuffed tube is mandatory when
vomiting is anticipated . . , . Regurgitation and aspira-
tion into the trachea may occur silently and unknown to
the anesthetist ....

“Berson and the writer working at the Charity Hospital
in New Orleans introduced preoperatively into the
stomach an insoluble dye, carmine red, which becomes
soluble and red when made alkaline with ammonia. They
noted that 15 per cent of 1,000 patients studied re-
gurgitated the dye into the pharynx. In half of these,
in other words, 7 per cent, the dye was identified in the
trachea. The anesthetist was unaware of the regurgita-
tion. The factors favoring regurgitation were as follows:

( 1 ) Difficult inductions . ... (2) The presence of the
stomach tube. The incidence was greater in patients who
had Levine tubes in situ . . . . ( 3 ) Intubated patients
showed an incidence of regurgitation close to 25 per
cent ... ( 4 ) Patients who were in the head up position
aspirated more frequently than those in the supine or
head down position .... (5) The incidence of regurgi-
tation using Pentothal and nitrous oxide contrary to our
expectations was above the average of 15 per cent ....

1 he statement has been made that fluid and vomitus
cannot travel uphill. Obviously this statement is true,
but one must remember that vomitus can be sucked
uphill .... Vomiting during the recovery period is often
ascribed to anesthesia. However, many factors besides
anesthesia are involved, and anesthesia is only one of the
many causative mechanisms.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 2. Copyright by John S. Lundy.

THE GERIATRIC PATIENT AND ANESTHESIA, by

R. H. Barrett: J. Am. A. Nurse Anesthetists 24:239-
248, 1956.

“Just where does the geriatric age begin? .... Maybe
we should be guided by the old adage that ‘one is as
old or as young as one feels’ .... Anyone who is engaged
in the administration of anesthesia is engaged in a
dangerous profession. Every time you anesthetize a pa-
tient, the choice of life or death rests squarely in your
hands, and it makes no difference whether you are a
physician or a nurse. For this reason, it behooves all
of us to know something about the people we are put-
ting to sleep ....

"We are always dealing with an individual in the
practice of medicine .... See your patient pre-
operatively—before he has had pre-anesthetic medication,
preferably the day before surgery. If for no other reason
than from the purely humanitarian standpoint, I urge
that this visit be made by the anesthesia nurse as well
as the anesthesiologist . . . .Tell the patient what he
can expect— both before and after anesthesia and surgery
. . . . Tell the patient what you are going to give him
for anesthesia and approximately how you are going to
give it. At least, tell him what the initial part of your
procedure will be. If you have a post-anesthesia room
or recovery room in your hospital, be sure to tell your
patient that this is where he will be after surgery, so
that when he awakens, he will not think he is in the
wrong place . . . Ask the patient about his previous
anesthesia experience ....

“Having convinced— or attempted to convince— this
individual that he has a better chance of living during
anesthesia and surgery today than he has while crossing
the street in front of the hospital after his convalescence,
you proceed to order premedication, or, at least, check
what others may have ordered for you. With the ever
increasing popularity in the use of light anesthesia, for
even the most major of surgical procedures, adequate
premedication is more important than ever .... If
someone else has ordered the premedication on the case
you are going to do, be sure it is what you want for
the patient you are going to anesthetize. You are a
registered nurse, specially trained in anesthesia tech-
nology. You are about to embark on a life or death
procedure, and it is expected that you will put to use
all of the acumen that you have collected over the past
several years of your life. If you do not agree with the
premedication, or even the type of anesthesia that has
been ordered by someone else, find out why it was
ordered. It may be the best for the patient, but, be sure
you know why. You are morally, if not legally, respon-
sible for every patient you anesthetize ....

“If you work with an anesthesiologist, your problems

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157

Section on PAIN

are reduced a hundredfold. If you do not work with an
anesthesiologist, naturally, you will not emulate your
surgeon on internist, but, you do have a right to know
‘whys and why-nots’ of what you are trying to do ... .

“The anesthetic technique, which, in our hands, for
the past several years, has proved to be the safest for
aged and debilitated patients is a combination of nitrous-
oxygen and a muscle relaxant ....

“Our technique is to start first an infusion of 5 per
cent glucose in quarter strength saline solution in the
adequately premedicated patient. We do not use scopola-
mine even in the very aged. Nitrous oxide and oxygen,
in an 80-20 mixture, is administered for a few minutes
by face mask. It is important to use non-rebreathing
technique especially during the induction period, in
order that bodily nitrogen will be replaced by nitrous
oxide. Because nitrous oxide is a relatively mild analgesic,
it is necessary to attain optimum concentration. The non-
rebreathing technique also prevents build-up of carbon
dioxide. After the patient is asleep, 20 to 40 mg. of
succinylcholine are given intravenously through the in-
travenous tubing, and the posterior pharynx and larynx
are sprayed with a topical anesthetic solution. This
spraying can be done before induction, but the comfort
of the patient is not disturbed by delaying it until the
patient is asleep. For that very short period while the
muscle relaxant and the topical anesthetic are produc-
ing their optimum effects, administration of nitrous-
oxide and oxygen is resumed bv face mask. A cuffed
endotracheal tube is then inserted, under direct vision,
and the patient is carried on hand-assisted respiration
throughout most of the surgical procedure ....

“Routine blood pressure, pulse, and often electrocardi-
ographic tracings are followed. Intravenous fluids, in-
cluding blood, are given as needed. On completion of
surgery, the patient is allowed to awaken gradually ....
The practice of geriatric anesthesia today in any general
surgical hospital is the practice of clinical anesthesia
per se; and the practice of anesthesia itself, as a specialty,
is and always has been not the specialized knowledge of
what to do now, but rather, the acumen gained by study
and experience which qualifies one to know what to do
next.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 14. Copyright by John S. Lundy'.

BASAL HYPNOSIS BY THE RECTAL ADMINISTRA-
TION OF A MULTIDOSE THIOBARBITURATE
SUPPOSITORY (Preliminary report), by S. N. Al-
bert, H. N. Eccleston, Jr., J. S. Boling, and C. A.
Albert. Anesth. & Analg. 35:330-336, 1956.

“The rectal administration of sodium Pentothal and
sodium Surital in 10 per cent solution has gained some
popularity as a rapid acting basal hypnotic in adults
and children. The difficulties one encounters when ad-
ministering rectal solutions has greatly limited the daily
use of this technique .... Sodium Nembutal supposi-
tories are sometimes used for this purpose. The onset
of action is slow and quite frequently the patient is
agitated and difficult to control ....

“It was desirable therefore to develop a simple and
practical method whereby rapid-acting sodium thiobar-
biturates could be administered rectally from stock

preparations in tailored doses for each individual patient
with minimal discomfort. Sodium Pentothal or sodium
Surital were incorporated in a suppository, cylindrical in
shape and of uniform diameter and consistency. Each seg-
ment of the suppository contains a fixed amount of active
ingredients, and the total amount to be administered de-
pends on the length of the suppository used. The sup-
positories are inserted into the rectal pouch stimulating
the procedure of taking a rectal temperature ....

“Multidose suppositories containing sodium Pentothal
were administered to 85 patients. Sodium Surital sup-
positories were administered to 65 patients. The results
in both series were similar in effect and duration, so we
incorporated both series into one total of 150 unselected
cases with ages ranging from one month to 99 years ....

“Rapid and accurate dosage determination for each
patient is feasible without elaborate preparations. The
onset of hypnosis is rapid, occurring within 5-10 minutes.
Induction of anesthesia is smooth. There was no apparent
depression of respiration, change in the blood pressure
and the pulse rate after the administration of the sup-
positories. One may conceive a combination of slow and
rapid-acting barbiturates incorporated into a multidose
suppository in order to give a rapid induction and pro-
longed hypnosis utilizing tailored doses to fit the need
of each patient.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 5. Copyright by John S. Lundy.

•

PUDENDAL BLOCK: TWO NEW TECHNIQUES,

by Virginia Apgar: Anesth. & Analg. 36:77-78, 1957.

“In 1951, the technic of pudendal block was examined
critically with the hope of improving its success. In order
to perform a satisfactory block, it was necessary to
palpate the ischial spine transvaginally on each side. It
seemed a simple matter to direct a needle between the
first and second fingers to this site, and to redirect it
medially, to a point just inferior to the tip of the spine,
then to insert it to a depth of 1 cm. and inject the
anesthetic solution after aspiration to rule out intravas-
cular placement ....

“A second route for pudendal block has proved useful
for certain gynecologic procedures and in males under-
going eystometric examinations. The posterior approach
was suggested by observing the perineal anesthesia which
was obtained during posterior femoral cutaneous nerve
block performed by Lundy. The patient is placed in
the Sims’ position, and the upper leg is sharply flexed.
A line is drawn between the posterior spine and the tip
of the greater trochanter. This line is bisected by a per-
pendicular line, a technic similar to that used in sciatic
nerve block. About 6 to 7 cm. downward on the per-
pendicular line, a needle is inserted and advanced in a
slightly outward direction until bone is met. This bone
is the posterior surface of the ischial spine on which lies
the pudendal nerve .... This approach has been con-
sidered too hazardous for obstetrical use, because of the
proximity of the infant’s head. Aspiration to identify the
pudendal artery and vein is performed before injection
of the anesthetic solution.”

From John S. Lundy and Florence A. McQuillen: Anesthesia
Abstracts. Minneapolis: Burgess Publishing Company, 1957, vol.
45, page 9. Copyright by John S. Lundy.

158

THE JOURNAL-LANCET

1

Journal

I A III ■**' I SERVING THE MEDICAL PROFESSION OF MINNESOTA.

V W'W V NORTH DAKOTA. SOUTH DAKOTA AND MONTANA

Not by Bread Alone

WILLIAM S. MIDDLETON, M.D.
Washington, D. C.

In assuming this yoke, I wish to make it clear
that this is a medium of conduction and of
communication and not a measure of personal
subjugation.

To come to you today is indeed a privilege,
and I would take the prerogative, indeed, with-
out compunction, of changing the trend of your
thought, if possible, to the past and not to pro-
ject it into the future as has been done in the
past two days. It is significant that the begin-
nings of the modern therapy of tuberculosis had
rather insecure foundations. We are all familiar
with Thomas Sydenham’s preachments of horse-
hack riding and exercise in general in the seven-
teenth century, which were the prescription not
only bv choice but of necessity. The very begin-
ning of modem therapy of tuberculosis may be
traced to George Bodington s suggestion in 1840
that the tuberculous patient be sent to hospitals
built in the country. In his treatment of pulmon-
ary consumption, he therefore felt that there was
the necessity for an environment different from
that of the urban hospitals. To George Boding-
ton goes the chief credit for the initiation of the
sanatorium movement. This found direct expres-
sion in the suggestions and the activity of Her-
man Brehmer at Gorbersdorf in 1859, when the
rural sanatorium was begun in Germany and
physical exercise was continued at varying levels.

william s. middleton is chief medical director of
Veterans Administration, Washington, D.C.

This article is reprinted with permission of the
author from Transactions of the Sixteenth Confer-
ence on the Chemotherapi/ of Tuberculosis, Febrti-
ary 11 to 14, 1957, St. Louis, Missouri.

Indeed, the exercise was extended to such a de-
gree that his student, Peter Dettweiler, differing
from the master, started his own sanatorium at
Falkenstein in 1875. Dettweiler really set the
pace for the more modem conception of sanator-
ium treatment. Of course, there is the work of
Carl Spangler at Davos in Switzerland, again in
the same vein, and then in our own country,
there is the work of Edward Livingston Trudeau
at Saranac that so greatly influenced the move-
ment for the treatment of the tuberculous patient.
The “Little Red” sanatorium was the beginning,
and a great influence on medical thought and ac-
tion in this country stemmed from the movement
initiated by Trudeau. His immediate pupils and
his co-workers, Lawrason Brown and Edward
Baldwin, are familiar to all of you.

The tradition of Trudeau has been carried
down in the generations intervening from 1885,
w hen he commenced his sanatorium, which was
a true movement for the modernization of
treatment as it was recognized at the time. In
general, all this period is B. K., that is to say,
Before Koch. In that particular direction, we
have living examples. I would single out Dr. J.
Burns Amberson, except for the fact that in the
December number of the Review, I understand
from a very eminent authority, James Waring,
that he has taken to making mousetraps. In any
event, this movement, which carried over into
the present era, had begun before Koch. When
Koch made his observations on the discoverv of
the tubercle bacillus in 1882, he attempted to
apply that information to treatment. The story
of old tuberculin is familiar to all of you. With-

out denying to Robert Koch his tremendous con-
tribution, it became obvious early that old tuber-
culin was not to be an essential element in the
treatment of tuberculosis.

Then came the intervention of surgery. For
the beginnings of thoracic surgery, Carlos For-
lanini introduced the pneumothorax in 1892 or
1895. The date depends on whether Garrison or
Long is considered the authority. Succeeding
him and supplementing him independently, John
B. Murphy popidarized the method in this coun-
try in 1895 or 1898, depending again on whether
Garrison or Long is your authority. In my stu-
dent days, more radical measures of therapy in-
cluded Schede’s very active work and, later, the
catalyzing effect of World War I was felt. It so
happened that as the medical man on a chest
surgical team in World War I, I was thrown into
close contact with thoracic surgeons. Under Ma-
jor, later Lt. Col., John L. Yates, I had the op-
portunity to meet men who were making history
in this area of surgery: namely Gask, the Eng-
lishman; Lockwood, the Canadian; and Tuffier,
the Frenchman. These surgeons were working
under terrific handicaps, because the support of
anesthesia was not always secure and none of the
antimicrobial agents was yet available. Lilien-
thal, another American, did notable work in that
period. Sauerbruch, a German, often denying
contact with the outside world, was a notable
contributor. I woidd like to pay tribute to a
giant among them all — John Alexander — who,
in my judgment, in the post-World War I period,
gave the greatest impetus to surgery of the lung
in this country. He influenced more individuals
than any other surgeon in this field. John Alex-
ander and Ewarts Graham were the great leaders
of the movement in this country.

The period of which we are speaking is, of
course, the period B. C., that is to say, Before
Chcmothcrapij, or I might, if I had been a little
bit more prompted in taking poetic license, have
said B. W., Before Waksman. This innovation
has initiated an entirely new viewpoint in our
treatment of tuberculosis, not only from the
medical but also from the surgical standpoint.
Those of you who have gone through the pre-
antibiotic, preantituberculosis drug or B. C. pe-
riod have a clear appreciation of the advantage
that has been given us by streptomycin, para-
aminosalicylic acid, isoniazid, cycloserine, Pvra-
zinamide, and the other agents used in this par-
ticular direction. Without them, the surgery of
tuberculosis would revert to the immediate post-
World War I period. We have the great ad-
vantages of anesthesia and of the antimicrobial
agents.

From our present vantage point, it is impor-
tant to view the past as well as the future. The
battle is not won, and we cannot rest on our
oars in the assumption that things will go for-
ward at the accelerated rate of the recent past.
Are we losing some of the advantages of the B.C.
period? By dependence upon phvsical and
chemical agents, are we losing some of the ad-
vantages that the patients had at an earlier
stage? I think the answer to both these ques-
tions is in the affirmative. It behooves us to look
carefully to ourselves to determine in what
measure these advantages may be regained. In
the first place, it is accepted as an axiom that
there is no tuberculosis except from a tuber-
culous subject. There must be a source and then
a susceptible host. It is important in this concept
that we view the subject realistically. The ideal
of tuberculosis control is admittedly prevention.
Are we as carefully screening our populations
as we did B.C.? Are we as carefully educating
the public and the profession as we did? Whether
we wish to admit it or not, the great advance in
the preantituberculosis drug period, B. C., was in
the education of the laitv, to which the profes-
sion reacted rather slowly. In this educational
movement, we must not relax one iota as we
look to the future. In the next place, it is appar-
ent that the early recognition or case-finding
of tuberculosis is a vital issue. Even if we have
given every consideration to preventive meas-
sures, including use of BCG in its place, instances
of tuberculosis will continue to occur until the
sources are wiped out— the millenium of pre-
vention. Early recognition by proper screening
methods is familiar to all of you; we must never
neglect them. Thev may appear less spectacular
and more humble, if you please. Nevertheless,
they are the keystone to the ultimate control of
this disease, and then, in turn, follows the pro-
per application of treatment. We will not denv
for a moment that under sanatorium manage-
ment of rest, adequately balanced nutrition, and
fresh air, there were certain advantages. Do not
lose them simply because we have other more
readv measures, which may actually be short
cuts. In the last analysis, there is still an advan-
tage to be gained by sanatorium management.

We realize that in this program of earlv tuber-
culosis control, there is the necessitv for a close
rapport with the patient. This represents first
a matter of the education of the patient, his
family, and the community. No longer is the tu-
berculous patient a pariah in society. We have
definitely gained that vantage point. Further-
more, the long term of this illness has been a
challenge which has been met by educational

160

THE JOURNAL-LANCET

methods from the beginning. In the conquest of
the disease, the patient must conquer himself be-
fore he starts to conquer his illness. The family
educated to the point of accepting its particular
responsibility, the community accepting its place,
and the patient educated to the limits of his
capacity to accept information constitute a team
of resistance. This is the keynote to the proper
rapport between the patient and the physician.
The physician must realize the psychology of the
ill and appreciate that they are peculiarly ego-
centric. In spite of the traditional spes phthisica,
we know that each patient will have to be
trained to meet the situation with which he is
confronted. Unless there is an intimacy of con-
tact between physician and patient, we will not
have gained our primary objective of the cooper-
ative therapeutics so necessary for complete care.

There are a number of points of obvious weak-
ness in our present pattern. We may take first
the debit side of the sheet for the physician. It
must be realized that the patient is distressed
when he finds the physician more interested in
the etiology than in the host of the disease. He is
immediately disturbed when the physician, too
technical to come into grips with his patient’s
problems, loses contact in his abstraction. It is
perfectly true that we wish to advance scientifi-
cally; but the meticulous details of the labora-
tory must not come between the physician and
this human subject of disease. “For this is the
great error of our day in the treatment of the
human bodv, that physicians separate the soul
from the body.” That is not a personal state-
ment but a quotation from Plato. The day is
somewhat removed; but, the fact remains that
we cannot afford to permit any barriers to come
between us and the patient. This patient-physi-
cian relationship is never more intimate than in
the care of the tuberculous individual. We turn
to the credit side of the column. Let there be
good cheer in the contact with the patients. May
we never bring gloom to the sick room. Further-
more, the appreciation of the necessity for in-
terest in the patient’s welfare by the utilization
of every agency is imperative. We in the Veter-
ans Administration are not working in a vacuum
in this particular subject and field. We have the
support of the psychiatrists, clinical psycholo-
gists, and the great help of the supporting cast
in physical therapy, occupational therapy, nurs-
ing, special services, and social service. We have
the library, and we have the clergy. Do not
minimize anv one of these elements, because this

patient entrusted to our care is one who is de-
tached from his place in societv. Unless we
attempt to fill that void, we may, in truth, be
working in a vacuum. We turn to the institution
itself. There is a verv definite personality in
hospitals. Let yours be a warm, cheerful atmos-
phere rather than a cold, impersonal type.

It is perfectly true that we all have problems.
Whether in the Army, Navy, Air Force, United
States Public Health Service, civilian institutions,
or the Veterans Administration, the problem of
the irregular discharge presents itself. Every
irregular discharge is a discredit to the manner in
which the patient has been treated. Do not mis-
understand me. I do not think that all problems
are soluble. There are many of these problems
that have grown over the years; but they are on
the debit side of the ledger because, first, ade-
quate therapy has not been provided for that
given individual. In the second place, he has
been returned, a potential source of infection, to
home and society without arrest or adequate
treatment of his condition. I am greatly dis-
tressed when I go into our institutions and find
that there is a patient, or patients, who refuse
to undergo surgery. That does not mean that the
staff is always at fault; but it occurs to me that
there is a breakdown in the fine chain of com-
munication between medicine and surgery and
the patient. In each instance where morale is in
question, where there is a barrier between pa-
tient and physician, we should look first to our-
selves for the source and the answer. It is per-
fectly correct to turn our clinical psychologists
and psychiatrists loose on this group of patients.
They have given us a great deal of information
and assistance in this area. In this breach, there
must be an answer, and we should attempt to
ascertain it. Certainly, as we grow larger, as our
institutions become more and more involved, an
atmosphere of impersonality may prevail. If this
be the case, there is always the difficulty, first
for the patient, then for the family, then for the
community, to make their necessary contribu-
tions to what I have termed cooperative thera-
peutics. It behooves us, then, to take to heart
the facts that we have made great gains in medi-
cine and surgery and that the advantages of these
advances to the individual suffering from tuber-
culosis are stupendous. However, so that we
may not compromise this advantage, we should
look to the various supporting elements and re-
member that we cannot depend on the medicine
and surgery alone to effect the cure.

MAY 1958

161

The Development of Tuberculosis in a
Controlled Institutional Environment

ABRAHAM GELPERIN, M.D., Dr. P.H.

Chicago, Illinois

Present programs of tuberculosis prevention
in controlled institutional environments con-
sist primarily of screening and diagnostic pro-
cedures. Admission and periodic chest x-ray
films, initial tuberculin tests with regular repeat
testing of negative reactors, as well as bacterio-
logic examinations in suspected cases, are the
accepted routine. Within recent vears, chemo-
prophylaxis of children who are recent converters
is a growing adjunct.1 Some directors of pro-
grams are even giving adults the benefits of the
latter routine.2 The slowly declining morbidity
of tuberculosis in this country3 and the redirec-
tion of programming in some communities4'5 will
perforce result in a continuously lowering tuber-
culosis disease potential for all institutions.

It was considered that an evaluation of such
institutional programs would indicate to some
degree the effectiveness and usefulness of the
various facets of a control program. Two in-
stitutions were studied. One is a 5,000-bed facil-
ity for the care of the mentally retarded, the
Dixon State School, Dixon, Illinois. The other
is the 516-bed Veterans Administration Research
Hospital, Chicago, Illinois. The former is a part
of the State Welfare Department, and the latter
is a university affiliated general hospital. They
will be considered separately, since they are dis-
similar in patient populations and with some-
what different control programs.

DIXON STATE SCHOOL

Dixon State School draws its residents, as the
patients are called, from Cook Countv and the
counties to the West and Northwest. It is like
a town in some respects. The residents live in
one-story dormitory cottages. There is a general,
communicable disease, and tuberculosis hospital,
as well as facilities for education, recreation, and
rehabilitation.

abraham gelperin, former assistant superintendent
of the Dixon State School, Dixon, Illinois, is on the
staff of the Veterans Administration Research Hos-
pital, Chicago, Illinois.

Prior to 1952, there had been sporadic tuber-
culin surveys, the first occurring in 1943. Annual
chest x-ray films were instituted in 1947. In
1952, both 70 mm. films and tuberculin testing
which utilized the intracutaneous injection of a
1 to 1000 dilution of Illinois State Health De-
partment old tuberculin were instituted for all
residents on a semiannual basis. Of importance
is the fact that the key personnel involved have
remained. Information concerning the newly
diagnosed cases of tuberculosis for the period
1952 through 1956 and of all cases of active
disease for the previous five years was obtained.
In addition, the results of tuberculin tests on new
admissions during the 1952-1956 period were
studied.

During 1947 through 1951, a total of 115 in-
dividuals were diagnosed as having active tuber-
culosis. Of this number, 64.4 per cent were males,
some 8 per cent above the average male census.
Of the 112 total with pulmonary infections, 44
or 39.2 per cent had minimal disease, 50 or 44.6
per cent had moderately advanced, and 18 or
16.7 per cent had far advanced tuberculosis.

For the period 1952 through 1956, when an in-
tensified case finding program was instituted, a
total of 65 new cases of tuberculosis were found,
primarily through the x-ray program. In addi-
tion, 18 individuals had relapses of previouslv
“stable” disease. The seeming paradox is that
fewer cases were found during a period of more
intense search. The percentage of males re-
mained constant— 64 per cent of 80 patients with
pulmonary disease were men— 57.5 per cent had
minimal infection, 32.5 per cent had moderately
advanced, and only 10 per cent had far advanced
disease. There was, however, an 18 per cent in-
crease in diagnosed minimal cases.

Table 1 emphasizes the difficulty of making a
definite diagnosis of active tuberculosis even in
an institutional population. The time lag is a
serious handicap for control programs, especially
in the free-living population.4 Within this group
of 65 cases, there were 7 deaths. Three were
caused bv tuberculosis, 1 had an initial diagnosis

162

THE JOURNAL-LANCET

TABLE 1

MONTHS TO DIAGNOSIS OF 65 CASES NEWLY DIAGNOSED
DURING 1952-1956, BY DIAGNOSTIC CATEGORY

Months to
Diagnosis

Minimal

Moderately

Advanced

Far

Advanced Other Total

0 to 2

15

11

4

2

32

3 to 5

14

6

0

i

21

6 to 8

8

1

0

0

9

9 to 11

1

1

1

0

3

Total

38

19

5

3

65

TABLE 2

LENGTH OF STAY IN INSTITUTION PRIOR
TO DEVELOPMENT OF TUBERCULOSIS
1952-1956

Number of Number of

Years Patients

<1

3

1 to 2

0

2 to 3

0

3 to 5

3

5 to 10

16

10 to 15

22

15 to 20

8

20 to 30

12

30+

1

Total

65

of far advanced disease, and 2 were diagnosed as
having minimal infection. Rapidly progressive
disease developed in the latter in the face of
maximum therapy.

The tuberculin history of the 65 individuals
revealed that all were tuberculin positive at
time of diagnosis. However, further evaluation
showed that 19 had come to the institution with
negative skin reactivity. Four persons had tuber-
culin conversions during the one year prior to
development of active disease, 1 case converted
within the previous two years, and 2 individuals
converted during the previous three years. Of
the total, tuberculosis developed in the majority
some years after admission, as shown in table 2.
Two of the 3 patients who were reported to have
active disease within the first year revealed active
tuberculosis at time of admission.

The 1,472 admissions for the period 1952
through 1956 were studied. Of this number, 951
came from Cook County and 521 from the other
counties. Since the population characteristics
in Cook County are significantly different from
the rest of the population area, all data were
separated. Of the total admissions, 529 were not

residents of the Dixon State School as of January
1, 1957, because of death or absolute or condi-
tional discharge from the institution and were ex-
cluded from the study of this group. Sixty-one
per cent were under age 10, and 21 per cent were
age 20 and over. It was considered that the
status of the tuberculin reaction played no part
at all in their permanent or temporary absence.
Thus, the remaining 943 were evaluated.

Table 3 presents, in condensed form, a sum-
marization of the raw data. There was the ex-
pected sharp rise in the ratio of positive reactors
with increase in age. The total number of per-
sons with initial positive tests is small, reflecting
the preponderance of children in the new ad-
missions studied during this five-year period.

There were 56 tuberculin conversions in the
804 individuals with initially negative skin tests.
Table 4 shows the period of communal contact
prior to the tuberculin conversion. It was noted
that there was no particular living, educational,
recreational, or rehabilitation area that produced
any unusual number of converters. Except for 7
instances in the Cook County group, all con-
verters were over 15 years of age. None re-
ceived chemoprophylaxis. Clinical and x-ray
evidence of active tuberculosis had developed in
2 adults, 2 out of 33 tuberculin conversions in
age group over 20.

The tuberculosis control program for employ-
ees entails an initial tuberculin test with no re-
testing of negative reactors. There are routine
pre-employment chest x-ray films, which are
followed by a minimum of semiannual chest
x-ray films for all employees. During 1952
through 1956, active disease developed in 2 em-
ployees who had been working for some years.
Roth were considered to have had evidence of
“healed” tuberculosis infection. An even more
important service has been the uncovering of
suspected disease in a number of applicants and
their referral to appropriate health agencies.

VETERANS ADMINISTRATION RESEARCH HOSPITAL

The Veterans Administration facility, on the
other hand, is a general hospital treating adults
only. It is located in the major source population
area of the Dixon State School. The hospital
routine consists of a chest x-rav film only on
patients as they are admitted or as soon after-
ward as possible. There is the well-known chest
x-ray film program for all employees and, in
addition, a tuberculin testing program consist-
ing of an initial test with periodic retesting of
negative reactors. Prior to July 1956, the 2-
strength PPD technic was utilized. Subsequent
to the above date, a single test with intermediate

MAY 1958

163

TABLE 3

INITIAL TUBERCULIN TESTS AND CONVERSIONS BY SOURCE POPULATION, AGE GROUP, AND SEX

Age

groups

Initial

tests

Male

Conversions

Female

Initial

tests Conversions

Initial

tests

Total

Conversions

+

5

10

15

Cook

0- 9 -

196

0

125

3

-321

3

Countv

-f

14

7

21

10-19 -

65

10

66

4

131

14

+

32

23

55

20+ -

25

5

39

10

64

15

-f-

2

0

2

Other

0- 9 -

94

0

61

0

155

0

counties

+

11

2

13

10-19 -

53

3

45

3

98

6

+

22

11

33

20+ -

26

9

9

9

35

18

+

7

10

17)

County

0- 9 -

290

0

186

3

476)

52%

3

totals

+

25

9

34)

10-19 -

118

13

111

7

229)

ZO /c

20

+

54

34

88)

20%

20+ -

51

14

48

19

99)

33

TABLE 4

DURATION OF INSTITUTIONAL STAY PRIOR TO TUBERCULIN CONVERSION

Months

Sex

0-5

6-11

12-23

24-35

36+

Total

Cook

M

0

2

5

6

2

15

county

F

2

3

5

5

2

17

Other

M

i

2

5

2

2

12

counties

F

0

2

3

2

5

12

Total

3

9

18

15

11

56

TABLE 5

CLASSIFICATION OF EMPLOYEES ACCORDING TO EXPOSURE,

GROUP, OCCUPATION,

AND SEX IN V.A.

RESEARCH HOSPITAL

OCTOBER 1, 1956

Tuberculin

test

Total

Positive

Negative

Not

tested

Persons

Male

Female

Male Female

Male

Female

Grand total

752

288

219

83

139

19

4

Group A

28

14

10

3

1

0

0

Group B

724

274

209

80

138

19

4

Physicians

66

28

2

15

0

19

2

Nurses

117

1

60

0

56

0

0

Attendants

112

66

33

15

8

0

0

Laboratory personnel

48

17

9

10

12

0

0

Other

371

162

105

40

62

0

2

164

THE JOURNAL-LANCET

TABLE 6

PERSONNEL HAVING NEGATIVE TUBERCULIN TESTS ACCORDING TO
AGE, OCCUPATION, AND RACE IN V.A. RESEARCH HOSPITAL, OCTOBER, 1956

Total t White a r Non-white ■n

persons Total <30 yr. 30-49 yr. .51)*- yr. Total 30 yr. 30-49 yr. 50+ yr.

Grand total

222

154

81

Group A

4

2

1

Group B

218

152

80

Physicians

15

15

7

Nurses

56

56

44

Attendants

23

2

0

Laboratory personnel

22

18

10

Others

102

61

19

strength had been employed. A summary of the
tuberculin status of all employees as of October
1, 1956, is presented in tables 5 and 6. Group A
was comprised of those who had practically no
contact with patients and was quite small in
number at that time, only 28 of 752.

The information obtained on the entire group,
which was composed of all types of general
hospital personnel who had been present for
varying lengths of time since the hospital opened
in November 1953, does not mirror the effect
of the institution upon them. However, a sum-
mation of the results of tuberculin testing of
new employees and retesting at three-month
intervals for all within group B and at six-month
intervals for group A, in a hospital that does not
admit known cases of tuberculosis except in an
occasional temporary emergency, suggests that
the tuberculin conversions, as shown in table
7, are a function of the endemic area in which
the hospital is located. Of the 2 professional
groups most closely associated with patients, a
tuberculin conversion developed in only 3 of
the 80 nurses and 2 of the 13 doctors retested
within the year, October 1, 1956, to October 1,
1957. Of the 51 employees in the group with
minimal contact with patients, 7 showed tuber-
culin conversion, and 15 of the remaining 142
employees in group B also presented evidence
of a new subclinical tuberculous infection.

DISCUSSION

The basic question that arises concerns the func-
tion and puqiose of the tuberculin test. In cases
of pulmonary or other systemic diseases in which
tuberculosis is a differential diagnosis, the tuber-
culin test is a highly specific diagnostic pro-
cedure.6 However, the testing of either employ-
ees or resident patients in an institution and
faithful recording of the results does not in it-

57 16

68

39

25

4

1 0

2

2

0

0

56 16

66

37

25

4

8 0

0

0

0

0

12 0

0

0

0

0

1 1

21

11

10

0

7 1

4

4

0

0

28 14

41

22

15

4

TABLE 7

SUMMATION OF ONE

YEAR’S

TUBERCULIN

RETESTING, BY

EXPOSURE

GROUP

AND OCCUPATION

Exposure group

and

Tuberculin reaction

occupation

T otal

Positive

Negative

Group total

286

27

259

Group A

51

7

44

Group B

235

20

215

Physicians

13

2

11

Nurses

80

3

77

Attendents

40

5

35

Laboratory personnel

22

2

20

Others

80

8

72

self add anything to the control of tuberculosis.
Why do a tuberculin test?— tradition or more
information? How is it to be used? In children,
a recent tuberculin conversion may result in
chemoprophylaxis as well as the usual investiga-
tion of intimate contacts to possibly uncover the
source of the new tuberculous infection.

The report of the cooperative study of some
2,700 children under the sponsorship of the
United States Public Health Service was en-
couraging. These recent converters were separ-
ated into two groups; one received chemopro-
phylaxis and the other a placebo. There was a
significant reduction in the incidence of evident
tuberculous disease in the treated group. Coidd
not the same be done with adults? Certainly,
they are not less important. In reality, do we
know now, with the changed clinical character-
istics of tuberculosis as well as ecology, the
chances of active disease developing in a free-
living or institutionalized adult within either
months or years after the first invasion by the
tubercle bacillus? Would the effect of chemo-
prophylaxis be similar to that observed in child-
ren? The long-term effectiveness of any tuber-

MAY 1958

165

culosis control program must be an integral part
of planning. Tuberculosis constantly reminds us
that it frequently lives as long as its host.

The observations presented suggest that the
disease in the institution, as in the free-living
community, develops primarily in those who
have had contact with tubercle bacilli years
before they entered the institution or came to
our attention. The problem of tuberculin con-
version was significant in the adult group in the
Dixon State School, reflecting institutional in-
fections in spite of an intensive control program.
The part that sublinical infection plays in indi-
viduals without roentgenograph ic evidence of
active disease is a moot point.

Patients or residents in an environment such
as the Dixon State School are in much more in-
tense social contact with their peers than in anv
free-living community. The finding, during 1952
through 1956, of a fewer number of individuals
with tuberculosis than diagnosed prior to the
intensified campaign emphasizes the question
of subclinical dissemination, the real contribution
made by the yearly x-rays of all residents for the
period 1947 through 1951, and the reasons for
doing and ignoring the tuberculin test. The
Veterans Administration Research Hospital ex-
perience is considered to be primarily a reflection
of the tuberculosis endemic in the external com-
munity. A tuberculin testing program in an in-

stitution does the same for the institution. In
the latter instance, however, the opportunity is
at hand for doing something about the offending
community.

SUGGESTIONS

1. Utilize intermediate strength PPD or its
equivalent for all tuberculin surveys in order to
facilitate comparability of studies.

2. Initiate a cooperative study for adults simi-
lar to that just reported for children.

3. Institutions might attempt to segregate their
present patients or residents with negative tuber-
culin reactions and allocate tuberculin negative
new admissions and ward or cottage personnel
to such units.

4. An intensive study of institutionalized adults
might clarify a few of the reasons why only some
individuals suffer clinical relapse.

5. A considerable number of adults in whom
clinically evident tuberculosis does not develop
probably have periods of subclinical infectious-
ness, and the frequency parallels the present sex
and age specific morbidities.

6. The chemotherapy of abeyant tuberculosis
may be as rational as the specific treatment of
latent syphilis.

7. The incidence of active tuberculous disease
in recent adult tuberculin converters is also sig-
nificant, especially in institutions.

REFERENCES

1. Mount, F. W.: Prophylactic effects of isoniazed on primary
tuberculosis in children: preliminary report. Am. Acad. Pediat.
meeting, October 8, 1957.

2. Galinsky, L. J.: Personal communication.

3. Feldman, F. M.: How much control of tuberculosis: 1937-
1957-1977? Am. J. Public Health 47:1237, 1957.

4. Gelperin, A., Galinsky, L. J., and Iskrant, A. P.: Appraisal
of tuberculosis case finding. Pub. Health Rep. 70:761, 1955.

5. Gelperin, A.: Abeyant tuberculosis. Dis. Chest, in press.

6. Furculow, M.: On usefulness of tuberculin skin test. Am. J.
Public Health 46:1064, 1956.

Bacteremia caused bv gram-negative bacilli occurs fairly often in patients
with diabetes mellitus. Fasting blood sugar determinations for patients with
such bacteremia and blood cultures for diabetic patients with unexplained fever
are recommended.

The urinary tract is usually implicated as the source of infection, so that
prophylactic antibiotic therapy is advisable if any operative procedure or
manipulation of the urinary tract is contemplated. Vigorous antibiotic treat-
ment is mandatory if urinary infection exists. A combination of a streptomycin
compound and one of the tetracycline group of antibiotics is recommended for
treatment of gram-negative infections.

Of 137 patients treated for gram-negative bacteremia, 14 also had diabetes
mellitus. The coli-aerogenes group of organisms was responsible for the infec-
tion in 12 of the 14 diabetic patients, and the urinary tract was thought to be
the source for invasion of the blood stream in all but 1 patient.

William J. Martin, M.D., John A. Spittel, Jr., M.D., William M. McConahey, M.D.. and
Warren A. Bennett, M.D., Mayo Clinic, Rochester, Arch. Int. Med. 100:214-220, 1957.

166

THE JOURNAL-LANCET

Children of America Need Our Help

J. ARTHUR MYERS, M.D.

Minneapolis, Minnesota

THE AMERICAN SCHOOL HEALTH ASSOCIATION

with more than 6,000 members operates in a
most fruitful health field from the standpoint of
America’s most important asset— the good health
of its people.

In this country in 1954, there were 16,000,000
preschool children, 27,118,000 from 5 to 14 years
old, and 12,854,000 from 15 to 19. In our schools,
there are 1,000,000 professional and 200,000 non-
professional workers. Thus, the children and
school personnel members numbered 57,172,000
—approximately one-third of the nation’s popu-
lation.

Human minds are never so impressionable and
so retentive as during the period of childhood.
It is a common observation that throughout life
people have clearer and better memories of their
childhood experiences than of those which occur
subsequently.

just now I am enjoying some of my most
pleasant experiences to date from work done for
children, which emphasizes their retentive mem-
ories. In 1921, while chief of the medical staff
of a new special school for tuberculous children,
the opportunity came to examine and observe
children for the next quarter of a century when
more than 19,000 were examined. One of our
present research problems consists of locating,
inquiring about their health, and examining these
former children. Although many now reside at
distant points, the response to our inquiry has
been most gratifying. When located, some have
inserted special notes on the questionnaires;
others have written long letters expressing ap-
preciation for our efforts to help them when they
were little children. They have vivid memories
of just how they were examined, exactly what
was done, and the advice given them. It is the
receptiveness and retentiveness of the child’s
mind which makes health work for children so
worthwhile.

It is encouraging to learn how these individ-
uals, many of whom had lost one or both parents

Read on the occasion of the presentation of the
William A. Howe Honor Award hi/ the American
School Health Association, November 13, 1957,
Cleveland, Ohio.

or other members of their families from tubercu-
losis, have adhered to the health principles they
were taught as children. Not only have they had
periodic examinations, but they also have pro-
vided them for their children and, in some in-
stances, their grandchildren. Thus, tuberculosis
in their generation has been far less destructive
than it was among their parents and grandparents.

Although equal opportunities exist in all as-
pects of health work, my remarks will be limited
largely to the disease whose germs have taken
refuge in the bodies of more of the 57,000,000
children and personnel of our schools than any
other major pathogenic organism.

APPOINTMENT OF COMMITTEE ON TUBERCULOSIS

When Dr. Charles H. Keene was president of
the American School Health Association in 1934,
he recognized the seriousness of this problem,
not only in the schools but also in the nation.
That year he appointed a Committee on Tuber-
culosis. This disease was then, as now, a serious
national defense item. Dr. Keene realized there
was no possibility of solving the problem quickly,
but he was confident that it could be overcome
through America’s educational system. By en-
listing the support and cooperation of the 1,000,
000 teachers and arming them with the facts
about tuberculosis, that generation of children
should be so protected against and informed
about this disease that they could go through
life suffering less destruction from it than any
previous generation. Moreover, each succeeding
generation of children would become freer from
tubercle bacilli. When Dr. Keene appointed this
committee, generations that had already passed
through the schools were suffering terrible losses
from tuberculosis. Its mortality rate in the nation
as a whole was 58.5 per hundred thousand.
Sanatoriums everywhere were filled to capacity
and numerous persons on waiting lists had to
remain in their homes. Thousands had unknown
but contagious tuberculosis. In cities, 20 per
cent or more of the grade school children and in
colleges, even in the Midwest, approximately one-
third and in some of the eastern states more than
one-half of entering students had been contam-
inated with tubercle bacilli.

MAY 1958

167

It was Dr. Keene’s great hope that his Com-
mittee on Tuberculosis might develop a pro-
gram which would help solve this problem. It
is of historic interest that the first meeting of the
committee was held at Saranac Lake, New York,
in the former residence of Dr. E. L. Trudeau,
who wrote the following in 1905: “Education
should begin by teaching in the public schools
the main facts relating to the transmission of
tuberculosis, insisting in such teachings on the
value of hygienic measures of prevention.”

COMMITTEE DELIBERATIONS AND
RECOMMENDATIONS

During its early meetings, this committee con-
sidered various activities, hoping to find one that
would be practical and could be employed every-
where with assured success. From the beginning,
the members strongly recommended employment
of the tuberculin test among school children
everywhere. One of its activities consisted of
producing a map of the United States indicating
the incidence of tuberculin reactors among
school children. This map was published in the
bulletin of the National Tuberculosis Association
in 1937 with the thought that it would stimulate
interest and activity in tuberculin testing in the
schools throughout the country. Up to that time,
tuberculin testing had been quite spotty, and
not a great deal of information was available.
However, it was anticipated that it would soon
be used extensively and that the map would
show improvement from year to year.

As this project was well underway, almost
fanatic enthusiasm for x-ray film inspection of
the chest without tuberculin testing or any other
phase of an examination swept the country.
Members of the committee, who previously had
had extensive experience with x-ray inspection
and were cognizant of its serious limitations,
knew such a procedure could not possibly solve
the problem. Although attention was called to
these limitations, they were ignored and en-
thusiasm for x-ray film inspection alone ran so
high that tuberculin testing came almost to a
standstill.

For a while, except in a few places, it was
well-nigh sacrilege to mention the tuberculin
test. Even secretaries of tuberculosis associations
referred to the absurdity of administering this
test when the disease could be directly detected
with the x-ray film. They had not been informed
that the ordinary x-ray film of the chest enables
one to visualize only 75 per cent of the lungs;
that areas of disease must be gross and have
adequate consistency to obstruct x-rays before
they cast visible shadows on films; that the

cause of a disease can never be determined from
the x-ray shadows it casts; and that 10 per cent
or more cases of tuberculosis have extrathoracic
locations.

The committee knew that the tuberculin test
is the most accurate diagnostic procedure avail-
able; that it detects tuberculosis long before most
lesions evolve sufficiently to cast x-ray shadows;
that only persons who react to the test become
ill from the disease. Therefore, it was futile to
look for tuberculosis where it does not exist by
making x-ray film inspections of the chests of
persons who do not react to tuberculin.

It seemed likely that the flurry of enthusiasm
for x-ray film inspection alone would soon sub-
side and workers everywhere would return to
a fundamental program. Therefore, the commit-
tee proceeded to recommend tuberculin testing
everywhere despite its unpopularity.

CERTIFICATION OF SCHOOLS PROPOSED

In 1940, it was proposed that a project be de-
vised whereby schools would be certified on the
basis of tuberculosis control work in progress.
Of all the programs that had been discussed
since 1934, certification of schools seemed the
best. If it could be properly organized, more
could be accomplished toward tuberculosis erad-
ication than anything that had ever previously
been employed. It could not only eliminate
clinical and contagious tuberculosis from the
schools, but it could also provide fundamental
information to personnel and students alike
which would be valuable throughout the re-
mainder of their lives.

FIRST SCHOOLS CERTIFIED

It was thought that the certification of schools
project should be given a thorough trial in one
state before it was recommended nationally. A
state was selected in which tuberculin testing
had not been given up entirely for x-ray inspec-
tion. Qualifications for certification were estab-
lished, and the first group of schools was certi-
fied on October 15, 1945. For the period of the
demonstration in that state, the Committee on
Tuberculosis, American School Health Associa-
tion, appointed a state subcommittee consisting
of three physicians. An arrangement was made
whereby this subcommittee worked in close
cooperation with the state Tuberculosis and
Health Association. In that state, certification of
schools was found to be the most effective
method of stimulating interest and promoting
activity in tuberculosis work that had ever been
employed. Moreover, it insured an over-all re-
sponse never previously experienced. It remains

168

THE JOURNAL-LANCET

a major activity of that Tuberculosis and Health
Association.

CERTIFICATION INSURES EXCELLENT RESPONSE

The school certification project has been adopted
by several states. Wherever it has been used, it
has spelled the doom of the tuberculous teacher,
bus driver, other employees, and even the high
school student from spreading tubercle bacilli in
the school and community. The subject of the
project suggests that work is limited to the
schools. In reality, the school is the center of ac-
tivity, but the work is often extended to include
entire communities which the schools serve.
For example, when children are found to react
to the tuberculin test, sources of their infections
are sought among their adult associates, such as
parents, maids, farm hands, and grandparents.
Entire communities become interested in track-
ing down the source of infection in the school
children. This is a first-class method of finding
clinical cases of tuberculosis in the community.
For example. Wood and Mantz sought the source
of infection of tuberculin reactors among the
kindergarten and first grade children in Kansas
City, Missouri. By this method, they located 10
times more contagious cases of tuberculosis than
had ever been found by any other method, in-
cluding mass x-ray surveys. This is not a new
epidemiologic method. It has been in practice
in a few places with excellent results for more
than thirty years. School certification insures its
much wider use.

The program is now so well-established and
has been in operation sufficiently long that there
is no question about its value.

Apparently some members of our own organi-
zation are not aware of the qualifications for
school certification. Some have said that it would
not be possible to adopt this program because
there is so much tuberculosis in their areas.
Certification is based on tuberculosis control
work in progress. The number of tuberculin
reactors found or the number of cases of clinical
tuberculosis discovered has nothing whatsoever
to do with certification. The qualifications only
include testing of 95 per cent or more of the
students and 100 per cent of the personnel, x-ray
film inspection of the chest of all high school and
personnel reactors, and seeking the source of in-
fection of student reactors. Indeed, if every stu-
dent and every personnel member reacted to
tuberculin and 25 per cent had evidence of
clinical disease, such a school could be certified

been met.

A physician wrote that it would be impossible

to certify the schools in his state and, particu-
larly, in the area where he operates a sanatorium
because of the small response. He has admin-
istered the tuberculin test in schools for many
years but only to freshmen and senior high
school students. He stated that the response
varies from school to school and from year to
year and that 80 per cent is considered good.
Experience has proved undeniably that response
of students and personnel is directly in propor-
tion to the amount of effort put into the project
before examinations begin. Apparently, it is
generally true that if an announcement is made
that on a certain day a physician or nurse will
offer the tuberculin test, the response often does
not exceed 50 to 60 per cent. Under such circum-
stances, 80 per cent would be exceedingly high.
However, the 95 per cent plus response among
children and 100 per cent response in personnel
have been readily obtained in many places where
adequate preparation has been made. For ex-
ample, we began testing with tuberculin in a
selected group of city schools in 1926 and re-
tested in the same schools approximately every
ten years to determine the effectiveness of the
general tuberculosis control program in the area.
In 1926, 1936, and 1944, an announcement was
made only a few days before that on a certain
day the tuberculin test would be administered.
The children were to bring signed consents from
their parents. Although the response was reason-
ably good, it was never satisfactory. In 1954, it
was decided to offer these 24 schools certificates
if they met the qualifications. Therefore, an in-
tensive educational campaign was conducted
over a period of about two months. The nursing
staff of the health department and others partici-
pated. They met with parent-teacher organiza-
tions and conferred individually with principals
of schools and other administrators. They dis-
tributed explanatory printed material among par-
ents and the entire school personnel. Education-
al workers of the State Tuberculosis and Health
Association arranged for newspaper articles,
radio and television broadcasts, and a special
printed pamphlet describing the tuberculin test
was distributed to parents and school personnel.
An excellent organization was formed in each
school for the actual testing in which mothers
and health chairmen played an important role.
The whole procedure was thoughtfully and care-
fully developed from the time of its announce-
ment to completion.

School and community pride spurred person-
nel, parents, and the children themselves on to
the certification goal. It served as a powerful
incentive. For example, in the first school tested,

MAY 1958

169

1 teacher did not respond. On the day the tests
were read, seventy-two hours later, she was the
first to appear and requested the tuberculin test,
stating that she could no longer take the goading
of other members of personnel, parents, and even
several children who asked her if she was going
to prevent their school from receiving a certifi-
cate. In another school on the morning the test
was given, a kindergarten teacher informed the
principal that 6 children in her room were ab-
sent. The principal called each mother by tele-
phone and urgently requested that the children
be brought in at least long enough for the test.
Five promptly responded.

When the examinations actually began, the
response was almost unbelievable. Among the
11,984 children, 98.7 per cent responded, and,
in 23 of the 24 schools, 100 per cent of the per-
sonnel was tested and examined.

The only criticism that the committee has re-
ceived came from an organization that was con-
sidering introducing the program but had heard
that this project stimulates so much interest that
more activity would be demanded in the schools
and community than the available manpower
coidd perform. In reality, this was a marvelous
recommendation, as it indicates that certification
of schools overcomes complacency in the public
mind toward tuberculosis eradication. It will be
unfortunate, however, if workers in the afore-
mentioned area do not take advantage of this
opportunity to use the increased interest stimu-
lated by certification to procure adequate funds
to meet the demand.

The educational opportunity in certifying
schools is immense. The two- or three-month
preliminary campaign results in the citizenry
learning much about tuberculosis. This is inten-
sified as the day of testing approaches, which
becomes a red-letter day in the community.
Parents are eager and watching for the results
of the tests of their children. It is a well-estab-
lished fact in pedagogy that the best time to
convey information on any subject is when
people are personally interested. Moreover, actu-
al participation in a project is the best method
of teaching. In the school certification project,
therefore, every personnel member and at least
95 per cent of the students participate.

Where, for any good reason, it is not possible
to test 95 per cent of the students, a Class B
Certificate is available when 80 per cent or more
are tested. This is in recognition of special effort
with the hope that difficulties will he removed so
such schools may later qualify for Class A Certifi-
cates. However, 100 per cent of personnel must
he tested to qualify for a Class B Certificate.

INCOMPLETE PROGRAM DANGEROUS

An unfortunate practice has been in effect in
some places, which consists of testing only child-
ren in certain grades. The logic of such a pro-
cedure is difficult to understand. It fails by more
than 50 per cent to qualify as a good program.
It is hard to believe that such an anomalous
procedure could have been introduced because
of additional work required for a first-class pro-
gram. An experienced nurse or physician can
administer 300 tuberculin tests per hour with
ease. Thus, 1,000 persons can be tested in a
forenoon of a single school day. If this unsatis-
factory procedure is due to lack of funds, an
effort should be made to procure whatever
money is necessary by letting the citizenry of the
community know. There is probably no place in
this country where, if such a problem were
placed before the citizens, adequate funds would
not be forthcoming.

When the qualifications were being prepared
for certification of schools, the committee con-
sidered all such procedures hut decided they
were inadequate.

Moreover, the committee has never approved
relaxing requirements for an individual or a
group of schools. For example, members of
parent-teacher associations and nearly the entire
community involved had difficulty at first in
understanding why the failure of one personnel
member to meet the qualifications should cause
denial of certification of their school. The an-
swer was that, in several instances, the person
or persons who refused to be examined knew
they had pulmonary tuberculosis. When examin-
ation was demanded by the community, the dis-
ease was found. One contagious case of chronic
pulmonary tuberculosis can infect many others.
Therefore, no school can be certified if just one
personnel member refuses examination.

This is an especially good time to continue
or start the school certification project, as H.
R. Smith, long-time livestock commissioner in
Chicago, is soon to publish a book dedicated to
the farm youth of America. It is a history of the
tuberculosis eradication campaign among the
cattle of this country. Attention is called to the
tuberculin test, which has been the sole diagnos-
tic agent, and how official accreditation of coun-
ties which met the qualifications was so valu-
able. This took advantage of local pride, created
interest, and provided information. It required a
large sum of money, hut the American citizenrv
responded when it was sufficiently informed of
the importance of the program. In fact, members
of the veterinary profession have done more
tuberculin testing than any other group. Conse-

170

THE JOURNAL-LANCET

quently, they are